Form Library – Danimer Scientific

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 1-855-290-1413

Medical Benefit Information Effective August 1, 2023

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.
How to Find Your EOB Statement	Provides an easy-to-understand guide to help locate your EOB Statements
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.
COVID-19 OTC Test Claim Reimbursement Form	Use this form for your over-the-counter Covid-19 test reimbursement.

HealthiestYou

Getting Started	Wherever you go, talk to a doctor for free by phone or video 24/7
General Consultations	HealthiestYou can diagnose, treat and prescribe over the phone
Mental Health	A calm mind is a tap away
Dermatology	Welcome to a better way to get healthy skin

Ancillary Services

Medical FSA Limits and Regulations	2023 Limits and Regulations on Medical FSA
Dependent Care FSA Limits and Regulations	2023 Limits and Regulations on Dependent Care FSA
DCA Open Enrollment	Link to DCA Open Enrollment Video
Dependent Care FSA	Link to Dependent Care FSA Video
FSA Open Enrollment	Link to FSA Open Enrollment Video
What is an FSA and How Does it Work?	Link to a FSA Overview Video
HSA Contribution Limits and IRS Regulations	2023 Limits and IRS Regulations on HSA Contributions
HSA Open Enrollment	Link to HSA Open Enrollment Video
Why Should I Get a HSA	Link to HSA Informational Video
Paying for Braces with a HSA	Link to Paying for Braces with a HSA Video

Aflac Ancillary Benefit Information

Aflac Cancer Protection Policy - Georgia	This benefit summary outlines your cancer indemnity insurance option.
Aflac Cancer Protection Policy - Kentucky	This benefit summary outlines your cancer indemnity insurance option.
Aflac Cancer Protection Policy - New York	This benefit summary outlines your cancer indemnity insurance option.
Group Accident Insurance After Care Benefits	This benefit summary outlines your accident after care benefits.
Group Accident Insurance Hospitalization Benefit	This benefit summary outlines your accident hospitalization benefits.
Group Accident Insurance Initial Accident Treatment Benefit	This benefit summary outlines your initial accident treatment benefits.
Group Accident Insurance Life Changing Events Benefits	This benefit summary outlines your life changing events benefits.
Critical Illness Limited Benefit Plan	This benefit summary outlines your critical illness benefits.
Group Hospital Indemnity Plan	This benefit summary outlines the group hospital indemnity plan.

Guardian Ancillary Benefit Options 2023

Guardian Benefit Overview	This benefit summary outlines how your ancillary benefits with Guardian.
Guardian Dental Benefits	This benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits.
Guardian Vision Benefits	This benefit summary outlines how your vision plan works and provides you with a quick reference of your vision plan benefits.
Guardian Life Insurance	This benefit summary outlines how your life insurance works and provides you with a quick reference of plan benefits.
Short Term and Long Term Disability Insurance	This benefit summary outlines how short term and long term disability works and provides you with a quick reference of plan benefits.

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.
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

Precertification List	Procedures that commonly require precertification
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.