Form Library – DBL Law 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 Care Advocate call 855-255-7060

Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
PPO 6 2023 SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HSA 1 2023 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

HealthEZ Medical Claim Reimbursement Form	Fill out the Medical Expense Reimbursement Form and submit to HealthEZ when you have paid out of pocket for medical expenses.
WellDyne Pharmacy Reimbursement Form	Fill out the Prescription Reimbursement Form and submit to WellDyne when you have paid out of pocket for prescription expenses. This form can also be used for Covid-19 OTC reimbursement requests.
WellDyne COVID-19 Reimbursement Form	Fill out the Prescription Reimbursement Form and submit to WellDyne when you have paid out of pocket for prescription expenses. This form can also be used for Covid-19 OTC reimbursement requests.

Recuro Telemedicine

Recuro Flyer	Feeling better is just a click away!
24/7/365 Access to Doctors	Healthcare that makes cents!
Suffering from Cold or Flu?	Relief Is A Phone Call Away

HealthEZ Resources

Understanding Your ID Card	Provides an easy-to-understand summary about how to read your HealthEZ ID card.
Boost Your Baby	HealthEZ offers maternity support by providing education and resources to promote a healthy pregnancy through postpartum
HealthEZ EZPay	Manage all your medical expenses in one simple spot with EZpay. Everything you need is at your fingertips in the free HealthEZ app.
HealthEZ EOB Sample	View a sample of your HealthEZ Explanation of Benefits (EOB)
HealthEZ Statement Sample	View a sample of your HealthEZ Statement
How to find your EOB's & Statements	How to find your EOB's & Statements

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. 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.

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.

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.