FSBP Member Forms &
Brochures Library
FSBP Brochures & Forms to help you understand your coverage.
New Brochures for 2023
2022 Brochures
2022 FSBP Plan Brochure
2022 FSBP Summary of Benefits
2022 FSBP Wellness Brochure
2022 AFSPA Brochure
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 Form
Authorize a personal representative to obtain/discuss protected health information with us
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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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2023 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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2022 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.
