Form Library – Cappadonna Electrical Contractors

Form Library

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 844-204-3759

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.
EZSPD©	An EZ to understand, short version of your Legal SPD
SBC Copay Plan	The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
SBC HSA Plan	The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.

Pharmacy Information

PPO Plan EHiM Pharmacy Benefit Summary	Provides a high level overview of your pharmacy benefits.
HRA Plan EHiM Pharmacy Benefit Summary	Provides a high level overview of your pharmacy benefits.
EHiM Mail Service Overview	Provides on overview on the benefits of EHiM Mail Service.
EHiM Generics	This guide provides information on how to save money by choosing quality, cost-effective alternatives to brand medications.

Plan Documents

Summary Plan Description	Provides detailed information about your medical benefits.
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.

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.