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Form Library

Foreign Service Benefit Plan Form Library

Below are official plan documents you may need to properly understand or receive benefits under your plan.

Member Forms & Documents
Title Description Download
OFFICIAL PLAN BROCHURE 2019 FSBP Plan Brochure PDF
SUMMARY OF BENEFITS & COVERAGE CHART 2019 Summary of Benefits & Coverage Chart PDF
OFFICIAL PLAN BROCHURE 2018 FSBP Plan Brochure PDF
SUMMARY OF BENEFITS & PROGRAMS 2018 Summary of Benefits & Programs PDF
SUMMARY OF BENEFITS & COVERAGE CHART 2018 Summary of Benefits & Coverage Chart (SBC) PDF
MEMBER FORMS Provider Nomination Form PDF
MEMBER FORMS Medical Claim Form PDF
MEMBER FORMS Urine Drug Testing Coverage Guidelines PDF
MEMBER FORMS EFT/Direct Deposit Authorization form PDF
MEMBER FORMS Authorization for Release of Protected Health Information (PHI) form PDF
MEMBER FORMS 2018 Deemed Exhaustion Notice PDF
MEMBER FORMS Wellness Incentive Claim Form PDF

 

Quality Management Documents
Title Description Download
Member Document CAHPS Member Satisfaction Scores PDF
Member Document HEDIS Clinical Performance Scores PDF
Member Document Program Description - Quality Management FEHBP PDF
Member Document Provider Satisfaction Post-Call Survey Scores - San Antonio, TX PDF
Member Document Provider Satisfaction Post-Call Survey Scores - Scottsdale, AZ PDF