Form Library – Remote Imagery Technologies Benefits

Form Library

Everything you need in one place.

Below you’ll find links to information and forms, which you can view or download and print.

If you prefer talking with a HealthEZ representative, call 888-588-6521

Medical Benefit Information

2025 Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
2025 Copay Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2024 Summary Plan Description (SPD)	Provides information on how the medical plan operates, when employees are eligible for benefits, how benefits are paid, and much more. Note, HealthEZ will no longer administer vision benefits effective 2/28/2025. Please contact your Human Resources representative for additional information on vision benefits.
2024 Dental Summary Plan Description (SPD)	Provides information on how the dental plan operates. Note, HealthEZ will no longer administer dental benefits effective 2/28/2025. Please contact your Human Resources representative for additional information on dental benefits.

Claim Reimbursement Forms

Medical Expense Reimbursement Form	Fill out the Medical Expense Reimbursement Form and submit to HealthEZ when you have paid out of pocket for medical expenses.
Prescription Reimbursement Form	Fill out the Prescription Reimbursement Form and submit to your Pharmacy Benefit Manager (PBM) when you have paid out of pocket for prescription expenses.

Preventive and Wellness Services

Preventive and Wellness Services	Provides information on your common preventive and wellness services.

Precertification

Precertification List	Provides a general overview of common services that require precertification. For specifics, please contact the number at the top of this page.

Coordination of Benefits

Coordination of Benefits (COB) Letter	A Coordination of Benefits (COB) letter is sometimes needed to process claims if you are covered by more than one health plan. It clarifies who pays what by determining which plan is the primary payer and which is secondary. Members will be notified if this form is required.

Important Notices

Your Rights and Protections Against Surprise Medical Bills	When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
Notice of Electronic Disclosure	Notice of Electronic Disclosure of Employee Benefit Notices, Summary Plan Description and Plan Amendments
Paper Employee Notices	Acknowledgement of Paper Employee Benefit Notices
Children's Health Insurance Program (CHIP) Notice	Explains how your eligibility for Medicaid or CHIP may qualify you for premium assistance to pay for your employer's health coverage
COBRA Notice	Explains your right to continue health benefits, if you were to lose them through your group health plan.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice	Explains how personal health information about you may be used and disclosed.
Newborn Act Notice	Explains how important protections for your members and their newborn children.
Special Enrollment Notice	Explains your right to enroll in your group health plan, if you lose your "other" health coverage.
The Genetic Information Nondiscrimination Act (GINA) Booklet	Explains how discrimination on genetic information is prohibited in group health plan coverage
Women's Health and Cancer Rights Act of 1998	Explains important protections for those who choose to have breast reconstruction, in connection with a mastectomy.
HealthEZ Privacy Policy	A summary of key provisions of our Privacy Notice.