Form Library – Rancho Markets

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 1-844-281-5215

2024 Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
Información sobre beneficios	Proporciona una información de alto nivel sobre sus HealthEZ beneficios médicos.
Copay Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Plan de Copay SBC	Ofrece un resumen fácil de entender sobre los beneficios y la cobertura de un plan de salud.
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 CerpassRx when you have paid out of pocket for prescription expenses. This form can also be used for COVID-19 OTC reimbursement requests

HealthiestYou Information

HealthiestYou Overview	Convenient and affordable access to licensed doctors by web, phone on by the app.
HealthiestYou FAQ	Answers to frequently asked questions.
HealthiestYou - How to get started	Explains how to access a doctor for free by phone or video 24/7.
Talk To a Doctor	Explains how you can talk to a doctor.
HealthiestYou Spanish Overview	Convenient and affordable access to licensed doctors by web, phone on by the app.
HealthiestYou 24/7 Spanish Instructions	Instructions for 24/7 access in Spanish.
HealthiestYou - Mental Health	Get confidential therapy quickly and conveniently.
HealthiestYou - Dermatology	Get healthy skin with HealthiestYou Dermatology.

Machine Readable File

Machine Readable File - AetnaNetwork	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.

Preventative Wellness Services

Preventative Wellness Services	Provides information on your common preventative 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.