Individual Forms and Medicare Products
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Be sure to keep a copy for your records.
Individual Products |
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|---|---|---|
| Applications and/or Miscellaneous Change Forms | Form # | Revision Date |
| Non-Underwritten Changes Miscellaneous Change Form |
IND-MCF-Non-UW-1 | 06/07 |
| Underwritten Changes Miscellaneous Change Form |
IND-MCF-UW-1 | 06/07 |
| BlueEdge Individual HSA Application/Miscellaneous Change Form |
BLUE EDGE-IND-HSA-APP/MCF-3 | 08/09 |
| BlueEdge Individual HSA Special Offer Application |
BLUE EDGE-IND-HSA-APP(SO)-1 | 08/09 |
| Application/Miscellaneous Change Form for Foundation Hospital Care |
PPO-IN HOSPITAL-APP/MCF | 04/07 |
| MSA Blue Application/Miscellaneous Change Form |
IND-CMM-APP/MCF | 01/07 |
| PPO Select Basic Application |
PPO-IND-CCHBP-App.(B)-2 | 04/07 |
| PPO Select Basic Miscellaneous Change Form |
PPO-IND-CCHBP-MCF(B)-2 | 01/07 |
| PPO Select Value Care Application/Miscellaneous Change Form |
PPO-IND-VALUE-APP/MCF-1 | 04/07 |
| PPO Select Value Care (Formulario de cambios de informacion de la solicitud/general para cobertura individual) |
FORMULARIO NRO.PPO-IND-VALUE-APP/MCF-1 | 04/07 |
| SelecTEMP PPO Temporary Individual Coverage Application |
PPO-STM-3-APP-2 | 04/09 |
| Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series III) |
IND-APP/MCF-1 | 04/07 |
| Special Offer Application (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series III) (62 KB) |
IND-APP(SO) | 02/06 |
| Solicitud/Formulario de cambios miscelaneos |
IND-APP/MCF-1 | 04/07 |
| Outline of Coverage and Patient Protection Act Disclosure Statements | Form # | Revision Date |
| BlueEdge Individual HSA Outline of Coverage Use this form with policies effective prior to January 1, 2010. |
PPO-BLUEEDGE-INDL-HSA-OLC-6 | 08/09 |
| BlueEdge Individual HSA Outline of Coverage Use this form with policies effective January 1, 2010 or later. |
PPO-BLUEEDGE-INDL-HSA-OLC-6 | 01/10 |
| BlueEdge Individual HSA Patient Protection Act Disclosure Statement |
PPO-BLUEEDGE-INDL-HSA-PPA-5 | 01/10 |
| Foundation Hospital Care Outline of Coverage |
PPO-IN HOSPITAL-OLC-2 | 12/08 |
| Foundation Hospital Care Patient Protection Act Disclosure Statement |
PPO-IN HOSPITAL-PPA-2 | 01/10 |
| PPO Select Basic Outline of Coverage |
PPO-CCHBP-OC-3 | 12/08 |
| PPO Select Basic Patient Protection Act Disclosure Statement |
PPO-CCHBP-PPA-3 | 01/10 |
| PPO Select Value Care Outline of Coverage |
PPO-IND-VALUE-OLC-3 | 12/08 |
| PPO Select Value Care Patient Protection Act Disclosure Statement |
PPO-IND-VALUE-PPA-2 | 01/08 |
| SelecTEMP PPO Outline of Coverage |
PPO-STM-3-OLC-1 | 12/08 |
| SelecTEMP PPO Patient Protection Act Disclosure Statement |
PPO-STM-3-PPA | 01/06 |
| PPO Select Choice Outline of Coverage (Series III) |
PPO-SELCHOICE-3-OLC-3 | 12/08 |
| PPO Select Choice INFORMACION GENERAL DE LA COBERTURA REQUERIDA |
PPO-CHOICE-3-OLC-2SP | 01/08 |
| PPO Select Choice Patient Protection Act Disclosure Statement (Series III) |
PPO-SELCHOICE-3-PPA-3 | 01/08 |
| PPO Select Saver Outline of Coverage (Series III) |
PPO-SELSAVER-3-OLC-3 | 12/08 |
| PPO Select Saver INFORMACION GENERAL DE LA COBERTURA REQUERIDA |
PPO-SAVER-3-OLC-2SP | 01/08 |
| PPO Select Saver Patient Protection Act Disclosure Statement (Series III) |
PPO-SELSAVER-3-PPA-2 | 01/08 |
| Select Blue Advantage Outline of Coverage (Series III) |
PPO-SELBLU-ADV-3-OLC-3 | 12/08 |
| Select Blue Advantage INFORMACION GENERAL DE LA COBERTURA REQUERIDA |
PPO-SELBLUE-ADV-3-OLC-2SP | 01/08 |
| Select Blue Advantage Patient Protection Act Disclosure Statement (Series III) |
PPO-SELBLUE-ADV-3-PPA-2 | 01/08 |
| General Miscellaneous Forms | Form # | Revision Date |
| Automatic Premium Payment Authorization Agreement |
51436.1209 | 12/09 |
| Acuerdo de autorizacion para el pago de prima automatico |
49218.1007 | 10/07 |
| BlueEdge Individual HSA Sales Brochure |
47054.1009 | 10/09 |
| BlueEdge Individual HSA Amendment (Effective 1-1-10) |
51849.0110 | 01/10 |
| List Bill Agreement |
51178.0109 | 01/09 |
| Producer Supply Order Form |
8706.807-0110 | 01/10 |
| Continuation of Coverage Request Form |
47133.0109 | 01/09 |
| Series III Comparison Chart |
47637.0407 | 04/07 |
| Texas Special Offer and Transfer Guide |
N/A | 10/08 |
| Hallmark Web Site Rate Action Enhancements Instructions |
N/A | 06/07 |
| Multiple Dependent Applications Instructions |
N/A | 05/08 |
| Mail Order Form - Prime Mail Pharmacy |
40690-1005 | 10/05 |
| Prescription Reimbursement Claim Form |
40959-704 | 07/04 |
| Standard Authorization to Use or Disclose Protected Health Information (PHI) |
N/A | 09/07 |
| Dental Miscellaneous Forms | Form # | Revision Date |
| Dental Supply Order Form |
40111-0809 | 08/09 |
| Dental Indemnity USA Monthly Premium Rate Guide |
N/A | 04/04 |
| Dental Indemnity USA Contract |
IND-DEN-2 | 06/07 |
| Dental Indemnity USA Outline of Coverage |
IND-DEN-2 OLC-1 |
09/08 |
| Scheduled Benefit Plan - Region II |
TXGRGNII | 04/03 |
| Scheduled Benefit Plan - Region IV |
TXGRGNIV | 04/03 |
Medicare Products
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.
| Medicare Supplement | Form # | Revision Date |
| Medicare Supplement Rate Card |
30121.0110TX | 01/10 |
| Medicare Supplement Product Guide |
31263.0110TX | 01/10 |
| Medicare Supplement Combo Mailer |
30087.0110TX | 01/10 |
| Medicare Supplement Outline of Coverage |
UWMSP-OC (A,D,F,G,K&L)-P | 01/10 |
| Medicare Supplement Replacement Notice |
MSP-REPLNOT – 2 (AGT) | 07/05 |
| Medicare Supply Requisition Form |
30129.0409 TX | 04/09 |
| Medicare Supplement Application |
UWMSP–APP–3-P-MED-SEL | 01/09 |
| Medicare Supplement Sales Pack |
MS-AGENT-SALESBK Rev 01/09 | 01/10 |
| Medicare Supplement Blue Extras Discount Program |
31259.0110 TX | 01/10 |
| Medicare Select Network Hospital Listing |
51180.0210 TX | 02/10 |
| Protected Health Information (PHI) Authorization Form |
N/A | 09/07 |