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Plan Documents

Employee Benefit Plan

Download the Employee Benefit Plan.

Employee Dental Plan

Download the Employee Dental Plan.

Employee Benefit Plan Summary of Material Modifications

Download the Employee Benefit Plan Summary of Material Modifications for 2018.

Download the Employee Benefit Plan Summary of Material Modifications for 2019.

Summary of Benefits and Coverage

Download the Summary of Benefits and Coverage 2018.

Download the Summary of Benefits and Coverage 2019.

Uniform Glossary of Coverage and Medical Terms

Download the Uniform Glossary of Coverage and Medical Terms.

Summary of Benefits and Coverage – Español

Download the Summary of Benefits and Coverage 2018 – Español.

Download the Summary of Benefits and Coverage 2019 – Español.

Glosario de cobertura de salud y términos médicos

Download the Glosario de cobertura de salud y términos médicos.

Member Forms

HIPAA Authorization Form

Download the HIPAA Authorization Form.

Medical & Dental Card Request Form

Download the Medical &Dental Card Request Form.

Dependent Verification Form

Download the Dependent Verification Form.

Tobacco Use Affidavit

Download the Tobacco Use Affidavit.

Additional Forms

For additional forms go to www.houze.org/langdale.

Provider Forms

Form W-9

Download a Request for Taxpayer Identification Number and Certification Form.

Preauthorization Form

Download a Preauthorization Form.

Access Your Member Portal

Log in to the Member Portal to access:

  • Your Medical & Dental Claims History
  • Your Explanations of Benefits (EOBs)

Please Note: Flexible Spending Accounts and Vision Insurance are not administered by TLC.

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Login to view Benefits and Claims

Login to view Pharmacy Benefits and Claims

Login to view ELAPulse - Balance Bill Service (Hospital & Facility Bills)

View the ELAPulse Member Guide