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 844-839-6735

Medical Benefit Information
 
Benefit Overview Provides a high level overview of your medical benefits.
Enrollment Form This form is to be filled out if electing medical benefits.
Paul's Valley Benefit Guide Provides an overview of all medical benefits offered including; disability, medical and dental.
EZSPD An EZ to understand, short version of your Legal SPD
$1,500 HSA Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Copay Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
$5,000 HSA Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Teledoc Benefit Information
 
MDLIVE Overview MDLIVE gives you and your family easier access to doctor visits whenever you need them. It’s a great addition to your benefits package that can help you get medical care that’s convenient for your life.
Pharmacy Benefit Information
 
MagellanRx Member Portal Guide This guide provides step-by-step directions on using your MagellanRx secure member portal.
MagellanRx Mail Service Order Form Use this form for mail order prescriptions from MagellanRx.
MagellanRx Mail Service FAQ This guide provides information on ordering your medication by mail, and frequently asked question.
MagellanRx Generics This guide provides information on how to save money by choosing quality, cost-effective alternatives to brand medications.
MagellanRx Medication Adherence This guide provides information on promoting healthier outcomes and reducing medical complications.
MagellanRx Cares This guide provides information on the MagellanRx Cares program.
Plan Documents
 
Summary Plan Description Provides information on how the medical plan operates, when employees are eligible for benefits, how services and benefits are calculated, when benefits become vested, when and in what form benefits are paid, how to file claims for benefits, and much more.
Marketplace Notice Explains options for purchasing health coverage through the Insurance Marketplace.
CMS Medicare Part D Notice Provides information for eligible Medicare Part D members on whether or not your current prescription drug coverage is creditable compared to Medicare's.
Health Savings Account (HSA) Forms & Information
 
HSA Overview Provides a high level overview on HSA’s, eligible expenses, contributions, and much more.
HSA Enrollment Form This form is to be filled out if electing a Health Saving’s Account.
Other Benefits and Forms
 
AirMedCare Overview Learn about AirMedCare's Fly-U-Home program.
AirMedCare Enrollment Form Print and fill out this form to enroll in AirMedCare's Fly-U-Home program.
EMPAC Employee Assistance Program Read this flyer to learn about what EMPAC has to offer with its Employee Assistance Program.
Colonial Life Flyer Speak to a doctor anytime, anywhere. This flyer provides information on how it works and steps to activate your account.
MDLive Employee Activation This flyer will walk you through your account activation, the website and much more.
United of Omaha Life Insurance Benefits Summary Learn about the benefits of United of Omaha Life Insurance and its eligibility requirements.
Mutual of Omaha Basic Term Life Learn about Mutual of Omaha's Basic Term Life Insurance policy, its benefits and eligibility requirements.
Voluntary Term Life Insurance Benefits Summary Learn about United of Omaha's Voluntary Term Life Insurance, its benefits and eligibility requirements.
Short-Term Disability Insurance Learn about Mutual of Omaha's Short-Term Disability Insurance program, its benefits and eligibility requirements.
Colonial Life's Short Term Disability Learn about Colonial Life's Short Term Disability program along with a guide on how much to set aside to "protect" your paycheck.
Colonial Life Whole Life Insurance Learn about Colonial Life's Whole Life Insurance, its benefits and eligibility requirements.
Colonial Term Life Insurance Learn about Colonial Life's Term Life Insurance, its benefits and eligibility requirements.
Colonial Life Group Hospital Confinement Indemnity Insurance Learn about Colonial Life's Group Hospital Confinement Indemnity Insurance, its benefits and eligibility requirements.
Colonial Life Specified Critical Illness Insurance Learn about Colonial Life's Specified Critical Illness Insurance, its benefits and eligibility requirements.
Colonial Life's Cancer Insurance Provide yourself with financial protection through Colonial Life's Cancer Insurance.
Colonial Life's Accident Insurance Learn about Colonial Life's Accident Insurance, its benefits and eligibility requirements.
Delta Dental Program Highlights Read this flyer to learn more about Delta Dental's Insurance Program, its benefits and eligibility requirements.
Important Notices
 
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary of Plan Description, and Plan Amendments.
Paper Employee Notice Acknowledgement of Paper Employee Benefit Notices.
COBRA Notice Explains your right to continue health benefits, if you were to lose them through your group health plan.
Special Enrollment Notice Explains your right to enroll in your group health plan, if you lose your "other" health coverage.
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.
Newborn Act Notice Explains important protections for mothers and their newborn children.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice. Explains how medical information about you may be used and disclosed.
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.