Form Library – 3CLLC

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 1-888-701-3008

Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
Copay Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HSA Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
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.

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. This form can also be used for COVID-19 OTC reimbursement requests

Teladoc Forms

You've Got Teladoc	Talk to a doctor anytime, anywhere by phone or video.
Mobile App Set Up	Use this flyer to help set up the Teladoc Mobile App
Teladoc Web Registration	It’s quick and easy to set up your account online. Simply visit the Teladoc® website.

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. PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
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. PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.

Preventive and Wellness Services

Preventive and Wellness Services	Provides information on your common preventive and wellness services.

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.