Downloadable Forms for Medicare Products

 

Enrollment Forms

Stock # / Date Enrollment Forms Texas Form #
747876.0818 Medicare Supplement Under Age 65 Disability Application
Use this application when applying for U65 Disability Medicare Supplement Coverage with an Effective Date on or after January 1, 2020
TXMSAPPDISA
747871.0720 Medicare Supplement Application – Standard Rating Area 1
Use this application when applying for Medicare Supplement Coverage in Rating Area 1.
TXMSAPP Rev. 0221
752569.0121 Medicare Supplement Application – Standard Rating Area 1 (Spanish Version)
Use this application when applying for Medicare Supplement Coverage in Rating Area 1.
TXMSAPP Rev. 0221
747871.0720 Medicare Supplement Application – Med-Select Rating Area 1
Use this application when applying for Medicare Supplement Coverage in Rating Area 1.
TXMSAPP Rev. 0221
752569.0121 Medicare Supplement Application – Med-Select Rating Area 1 (Spanish Version)
Use this application when applying for Medicare Supplement Coverage in Rating Area 1.
TXMSAPP Rev. 0221
747871.0720 Medicare Supplement Application – Standard Rating Area 2
Use this application when applying for Medicare Supplement Coverage in Rating Area 2.
TXMSAPP Rev. 0221
752569.0121 Medicare Supplement Application – Standard Rating Area 2 (Spanish Version)
Use this application when applying for Medicare Supplement Coverage in Rating Area 2.
TXMSAPP Rev. 0221
747871.0720 Medicare Supplement Application – Med-Select Rating Area 2
Use this application when applying for Medicare Supplement Coverage in Rating Area 2.
TXMSAPP Rev. 0221
752569.0121 Medicare Supplement Application – Med-Select Rating Area 2 (Spanish Version)
Use this application when applying for Medicare Supplement Coverage in Rating Area 2.
TXMSAPP Rev. 0221
747871.0720 Medicare Supplement Application – Standard Rating Area 4
Use this application when applying for Medicare Supplement Coverage in Rating Area 4.
TXMSAPP Rev. 0221
752569.0121 Medicare Supplement Application – Standard Rating Area 4 (Spanish Version)
Use this application when applying for Medicare Supplement Coverage in Rating Area 4.
TXMSAPP Rev. 0221
747871.0720 Medicare Supplement Application – Med-Select Rating Area 4
Use this application when applying for Medicare Supplement Coverage in Rating Area 4.
TXMSAPP Rev. 0221
752569.0121 Medicare Supplement Application – Med-Select Rating Area 4 (Spanish Version)
Use this application when applying for Medicare Supplement Coverage in Rating Area 4.
TXMSAPP Rev. 0221

 

Enrollment Forms and Change Forms

Stock # / Date Enrollment Forms and Change Forms Texas Form #
748218.0220 TX Medicare Supplement Outline of Coverage – Standard Rating Area 1
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 1 with an Effective Date on or after May 1, 2020.
MS-OOC-A1-STND Rev. 10/19
752721.0220 TX Medicare Supplement Outline of Coverage – Standard Rating Area 1 (Spanish Version)
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 1 with an Effective Date on or after May 1, 2020.
MS-OOC-A1-STND Rev. 10/19
748386.0220 TX Medicare Supplement Outline of Coverage – Standard Rating Area 2
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 2 with an Effective Date on or after May 1, 2020.
MS-OOC-A2-STND Rev. 10/19
752723.0220 TX Medicare Supplement Outline of Coverage – Standard Rating Area 2 (Spanish Version)
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 2 with an Effective Date on or after May 1, 2020.
MS-OOC-A2-STND Rev. 10/19
748388.0220 TX Medicare Supplement Outline of Coverage – Standard Rating Area 4
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 4 with an Effective Date on or after May 1, 2020.
MS-OOC-A4-STND Rev. 10/19
752725.0220 TX Medicare Supplement Outline of Coverage – Standard Rating Area 4 (Spanish Version)
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 4 with an Effective Date on or after May 1, 2020.
MS-OOC-A4-STND Rev. 10/19
748218.0321 TX Medicare Supplement Outline of Coverage – Standard Rating Area 1
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 1 with an Effective Date on or after May 1, 2021.
MS-OOC-A1-STND Rev. 10/19
TBA Medicare Supplement Outline of Coverage – Standard Rating Area 1 (Spanish Version)
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 1 with an Effective Date on or after May 1, 2021.
TBA
748036.0321 TX Medicare Supplement Outline of Coverage – Med Select Rating Area 1
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 1 with an Effective Date on or after May 1, 2021.
MS-OOC-A1-CMB
TBA Medicare Supplement Outline of Coverage – Med Select Rating Area 1 (Spanish Version)
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 1 with an Effective Date on or after May 1, 2021.
TBA
748386.0321 TX Medicare Supplement Outline of Coverage – Standard Rating Area 2
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 2 with an Effective Date on or after May 1, 2021.
MS-OOC-A2-STND Rev. 10/19
TBA Medicare Supplement Outline of Coverage – Standard Rating Area 2 (Spanish Version)
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 2 with an Effective Date on or after May 1, 2021.
TBA
748382.0321 TX Medicare Supplement Outline of Coverage – Med Select Rating Area 2
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 2 with an Effective Date on or after May 1, 2021.
MS-OOC-A2-CMB
TBA Medicare Supplement Outline of Coverage – Med Select Rating Area 2 (Spanish Version)
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 2 with an Effective Date on or after May 1, 2021.
TBA
748388.0321 TX Medicare Supplement Outline of Coverage – Standard Rating Area 4
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 4 with an Effective Date on or after May 1, 2021.
MS-OOC-A4-STND Rev. 10/19
TBA Medicare Supplement Outline of Coverage – Standard Rating Area 4 (Spanish Version)
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 4 with an Effective Date on or after May 1, 2021.
TBA
748384.0321 TX Medicare Supplement Outline of Coverage – Med Select Rating Area 4
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 4 with an Effective Date on or after May 1, 2021.
MS-OOC-A4-CMB
TBA Medicare Supplement Outline of Coverage – Med Select Rating Area 4 (Spanish Version)
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 4 with an Effective Date on or after May 1, 2021.
TBA

 

Medicare Secondary Payer (MSP) Form and Information

Stock # / Date MSP Form and Information Texas Form #
753075.0421 Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions N/A
21092.0609 Information Regarding MSP Statute N/A
56064.0612 MSP Fact Sheet N/A

 

Miscellaneous Forms

Stock # / Date Miscellaneous Forms Texas Form #
730621.0419 ezBlue Payment Option Authorization Agreement N/A
82288.0919 Medicare Supplement List Bill N/A
30029.0911 Medicare Supplement Notice of Replacement TX-MS-NOR-2011-R1
749645.0219 Medicare Supplement Notice of Replacement TX-MS-NOR-2019 Y0096_ENR_TXNOR19_C
N/A Standard Authorization Form and other HIPAA Privacy Forms N/A

 

Other Plan Information

Stock # / Date Other Plan Information Texas Form #
N/A Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare N/A
729688.0220 Medicare Supplement Decision Guide Reader TXMSDG20
51180.0419 Medicare Select Network Hospital Listing N/A