Plan Forms – Ethos Group

Plan Forms

Forms, Notices, and more

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 1-844-804-8120

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.

Machine Readable File

Machine Readable File – Cigna 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 – 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.

Coordination of Benefits

Coordination of Benefits Form	Fill out the Coordination of Benefits form and submit to HealthEZ to document any secondary insurance coverage

Member Appeal Form

Member Appeal Form	Member Appeal Form

Precertification List

Precertification List	Common services that require precertification. For services not listed, contact the number at the top of this page for more information.

Important Notices

Paper Employee Benefit Notices	Acknowledgement of Paper Employee Benefit Notices
Notice of Electronic Disclosure	Notice of Electronic Disclosure of Employee Benefit Notices, Summary Plan Description, and Plan Amendments
Surprise Billing and Balance Billing Protections	Your Rights and Protections Against Surprise Medical Bills
CHIP Model Notice	Premium Assistance under Medicaid and the Children’s Health Insurance Program
Modelo de aviso de CHIP	Asistencia para el pago de primas bajo Medicaid y el Programa de Seguro Médico para Niños (CHIP)
COBRA Notice	General COBRA Notice
GINA Booklet	The Genetic Information Nondiscrimination Act
HIPAA Notice	HIPAA Privacy Notice
Newborns Act	Newborns’ and Mothers’ Health Protection Act
Special Enrollment Rights Notice	Special Enrollment Rights Notice
WHCRA	Women’s Health and Cancer Rights Ac