Form Library – Mt. Vernon School

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 888-284-7195

2023 Medical Benefit Information- Effective 7/1/23

2023 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.
2023 Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
2023 Copay Plan SBC	Provides an easy-to-understand summary about copay health plan’s benefits and coverage.
How to Find Your EOB Statements	Provides an easy-to-understand guide to help locate your EOB Statements
2023 HSA Plan SBC	Provides an easy-to-understand summary about HSA health plan’s benefits and coverage.

Teladoc

Teladoc Flyer	Provides an overview on how to utilize your TelaDoc services
App Setup	Provides step-by-step instructions on how to setup your TelaDoc account on the app
Web Registration	Provides step-by-step instructions on how to setup your TelaDoc account on the app

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

Machine Readable File

Machine Readable File – Aetna Network	Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.
Machine Readable File – Out of Network	Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.

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.