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Ph: (229)249-0940 • Fax: (229)249-9840 • Toll Free: (877)949-0940

Balance/Surprise Billing Protections Notice

Download the Balance/Surprise Billing Protections Notice.

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 2020.

Download the Employee Benefit Plan Summary of Material Modifications for 2021.

Download the Employee Benefit Plan Summary of Material Modifications for 2022.

Summary of Benefits and Coverage

Download the Summary of Benefits and Coverage 2020.

Download the Summary of Benefits and Coverage 2021.

Download the Summary of Benefits and Coverage 2022.

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 2020 – Español.

Download the Summary of Benefits and Coverage 2021 – Español.

Download the Summary of Benefits and Coverage 2022 – 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.

Affidavit - Spouse Eligibility Verification

Download the Affidavit - Spouse Eligibility 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.

FiveStar Telehealth Clinic Logo

COVID-19 Screening Form

Download the FIVESTAR Telehealth Clinic COVID-19 Screening Form.

New Patient Packet

Download the New Patient Packet.