Notice of Privacy Practices
Plan Documents
Balance/Surprise Billing Protections Notice
Plan Documents
Employee Benefit Plan
Employee Dental Plan
Employee Benefit Plan Summary of Material Modifications
Summary of Benefits and Coverage
Uniform Glossary of Coverage and Medical Terms
Summary of Benefits and Coverage – Español
Glosario de cobertura de salud y términos médicos
Member Forms
HIPAA Authorization Form
Medical & Dental Card Request Form
Dependent Verification Form
Affidavit - Spouse Eligibility Verification
Tobacco Use Affidavit
Additional Forms
Provider Forms
Form W-9
Preauthorization Form
COVID-19 Screening Form
Download the FIVESTAR Telehealth Clinic COVID-19 Screening Form.
New Patient Packet
Download the New Patient Packet 2025 Full Fillable.
Download the New Patient Packet 2025 Full.
