Medicare Supplement Forms
For your convenience, we've put together the following downloadable forms. Acrobat Reader software will enable you to download these PDF files. If you currently don't have the software, you can get a free copy from Adobe. 
You can also visit our section on how to download a PDF file for additional information.
| Medicare Supplement | Form # | Revision Date |
ezBlue Payment Option Authorization Agreement  (107 KB) |
31752.0311 | 03/2011 |
| Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare (717 KB) |
30092.0311 | 03/2011 |
| Medicare Supplement Underwritten Combo Outline of Coverage 1, 2, 3 (147 KB) |
UWMSP-OC-CDP | 11/2011 |
| Medicare Supplement Replacement Notice (108 KB) |
MSP-REPLNOT – 2 (AGT) | 07/2005 |
| Medicare Supplement Underwritten Application 4, 5, 6 (164 KB) |
UWMSP-APP-DP-MED-SEL | 06/2010 |
| Medicare Supplement Underwritten Member Kit (1.51 MB) |
MS DIRCOMUW BR – REV2 | 11/2011 |
| Medicare Select Network Hospital Listing † (256 KB) |
51179.0410 TX | 04/2010 |
| Standard Authorization Form to Use or Disclose Protected Health Information (PHI) (114 KB) |
SAF-TX | 01/2012 |
Not connected with or endorsed by the United States government of the Federal Medicare program.
The open enrollment period is the six-month period beginnning with the first day of the first month in which an individual is first enerolled for benefits under Medicare Part B.
No individual can be denied any Medicare Supplement policy sold by any Medicare Supplement issuer if the application is submitted during the six-month period beginning on the first day of the month in which you are enrolled in Medicare Part B
If you are on Medicare under age 65, you will also have a six-month open enrollment period when you reach age 65.
† Only certain hospitals are network providers under this policy. Check with your physician to determine if he or she has admitting privileges at the network hospital. If he or she does not, you may be required to use another physician at the time of hospitalization or you will be required to pay for all the expenses.
TXWEB1061 - Rev 07/11
