Employee Benefit Plan

Download the Employee Benefit Plan.

Download the Langdale SPD 2023.

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 2023.

Download the Employee Benefit Plan Summary of Material Modifications for 2024.

Summary of Benefits and Coverage

Download the Summary of Benefits and Coverage 2023.

Download the Summary of Benefits and Coverage 2024.

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 2023 – Español.

Download the Summary of Benefits and Coverage 2024 – Español.

Glosario de cobertura de salud y términos médicos

Download the Glosario de cobertura de salud y términos médicos.

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/next/benefits/langdale/.

Form W-9

Download a Request for Taxpayer Identification Number and Certification Form.

Preauthorization Form

Download a Preauthorization Form.