Form Library – Araz Group 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 952-896-9104

2024 Medical Benefit Information

2024 Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
APPO/Aetna HSA Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Elite Network HSA Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Medical 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.
Dental Summary Plan Description (SPD)	Provides information on how the dental plan operates.
2024 Medical and Dental Premiums	Provides an easy-to-understand summary of your premiums for your HealthEZ Medical and Dental Plan.
Vision Benefit Overview	Provides a high level overview of your vision plan benefits.
VSP/Reliance Standard Privacy Notice
HealthEZ Care Navigation Resources	Provides an overview of the medical management services provided through HealthEZ.

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.

2024 Reliance Standard Information

Voluntary Group Long Term Disability Overview	Provides a high level overview of your Voluntary Group Long Term Disability Insurance benefits
Group Supplemental and Dependent Life Overview	Provides a high level overview of your Group Supplemental and Dependent Life Insurance benefits
Supplemental and Dependent Life Insurance Premium Table	Provides an easy-to-understand summary of your Employee Bi-Weekly Premiums for your Supplemental and Dependent Life Insurance Plan
Voluntary AD&D Overview	Provides a high level overview of your Voluntary AD&D Insurance benefits
Voluntary AD&D Insurance Premium Table	Provides an easy-to-understand summary of your Bi-Weekly Premiums for your Voluntary AD&D Insurance Plan
Group Basic Life and AD&D Class 1 Overview	Provides a high level overview of your Group Basic Life and AD&D Class 1 plan highlights
Group Basic Life and AD&D Class 2 Overview	Provides a high level overview of your Group Basic Life and AD&D Class 2 plan highlights
Reliance Standard Enrollment Form	This form is to be filled out if electing a Reliance Standard Insurance plan
Employee Assistance Program Benefits Flyer	Provides an overview of your Employee Assistance Program benefits.
Employee Assistance Program Member Portal and App Flyer	Provides an overview of the Employee Assistance Program Member Portal and App.
Employee Assistance Program FAQs and Guidelines	Provides and overview of the Employee Assistance Program FAQs and Guidelines.

Pharmacy Information

Preventative Wellness Medication List	EHIM believes in the overall wellness of our members by way of prevention. This document is a summary of preventative medications.

WEX Benefit Information

WEX Login Participant Site	WEX login for HSA, FSA and COBRA

2024 401K Savings Plan

Ascensus 401(k) Participant Login	Ascensus 401(k) Participant Login
401K Savings Plan Summary Plan Description	Provides detailed information on how the 401K Savings Plan operates and much more.

EZfit Program Forms & Information

EZFit Program Highlights	Provides a high level overview of your EZFit program benefits.
EZFit Enrollment Form	This form is to be filled out if enrolling in the EZFit program.
EZFit Reimbursement Form	This form is to be filled out when needing reimbursements for the EZFit program.
LifeTime Fitness Corporate Membership Sign Up Link

Preventative Wellness Services

Preventative Wellness Services	Provides information on your common preventative wellness services.

Important Notices

Precertification List	Procedures that commonly require precertification
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.