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

Plan Documents

Employee Benefit Plan

Download the Employee Benefit Plan.

Employee Dental Plan

Download the Employee Dental Plan.

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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