FSBP Member Forms &
Brochures Library
FSBP Brochures & Forms to help you understand your coverage.
New Brochures for 2025
2024 Brochures
FSBP Forms Library
Forms
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FSBP Claim Form
Medical Claim form to submit for benefit reimbursement
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Health Benefits Election Form (SF 2809)
Health Benefits Election Form SF 2809 to for plan enrollment
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Authorized Representative Request Form
Authorize a personal representative to obtain/discuss protected health information with us
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FSBP Member Complaint and Appeal Form
Official form to submit a complaint or appeal
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FSBP Electronic Funds Transfer (EFT) Form PDF
The EFT Authorization Form allows the Plan to deposit funds into your U.S. bank account.
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FSBP Electronic Funds Transfer (EFT) Form ONLINE
The EFT Authorization Form allows the Plan to deposit funds into your U.S. bank account (online submission).
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FSBP Wellness Incentive Claim Form
Form to submit for FSBP Wellness Incentive Reimbursement
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FEHBP Urine Drug Testing Coverage Form
FEHBP Urine Drug Testing Coverage Form
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Express Scripts Prescription Home Delivery Form
Form to complete for Express Scripts prescription home delivery
Online Secure Forms
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Ask FSBP Benefits & Claims Questions ONLINE
Send us a secure message to ask a Health Benefits Officer about benefits or follow up on a status of a claim
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Ask FSBP Enrollment Questions ONLINE
Send us a secure message to ask about information or updates on your enrollment, request a new ID card, and other information about your enrollment
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Ask FSBP Open Season Enrollment Questions ONLINE
Send us a secure message to ask about Open Season enrollment
Documents
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2025 FSBP Summary of Benefits and Coverage (SBC)
This document shows you how you and the Plan would share the cost for covered health care services.
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2024 FSBP Summary of Benefits and Coverage (SBC)
This document shows you how you and the Plan would share the cost for covered health care services.
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How to Read Your Explanation of Benefits (EOB)
Learn how to read your EOB, a notification from the Plan explaining how your medical claims are processed.
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Notice of Privacy Practices
This document describes how medical information about you may be used and disclosed.
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Member Rights & Responsibilities
This document describes your rights and your risks as a patient when dealing with medical providers.
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Stop Health Care Fraud
This document has Information on how to protect yourself from health care fraud
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FSBP Participating Pharmacies
This document includes a list of FSBP participating pharmacies in the U.S.
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Rx Home Delivery in Foreign Countries
This document has guidelines to obtain up to a 1-year supply of medication when living in a foreign country
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Glossary of Health Coverage and Medical Terms
This document includes a glossary that defines many commonly used terms.
