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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 SupplementForm #Revision Date
ezBlue Payment Option Authorization Agreement  (107 KB)31752.031103/2011
Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare  (717 KB)
Medicare Supplement Underwritten Combo Outline of Coverage  1, 2, 3 (147 KB)UWMSP-OC-CDP-201/2013
Medicare Supplement Replacement Notice  (463KB)TX-MS-NOR-2011-R109/2011
Medicare Supplement Underwritten Application  4, 5, 6
(164 KB)
Medicare Supplement Underwritten Member Kit 
(1.51 MB)
Medicare Select Network Hospital Listing  (256 KB)51179.0410 TX04/2010
Standard Authorization Form and other HIPAA Privacy FormsN/AN/A


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.

1 Any Medicare Supplement insurance policy is guaranteed renewable. Rates are subject to change.

2 Benefit exclusions and limitations may apply to a Medicare Supplement insurance plan.

3 Do not send money to Blue Cross and Blue Shield of Texas in response to this advertisement.

4 In order to obtain coverage under a Medicare Supplement insurance plan, an application must be completed.

5 In total we sell Medicare Supplement insurance plans A, F, F-HD, G, K, L and N, as well as Medicare Select versions of F, G, K, L and N. Policy numbers are: UWMSP(A)-2010, UWMSP(F)-2010, UWMSP(F-HD)-2010, UWMSP(G)-2010, UWMSP(K)-2010, UWMSP(L)-2010, UWMSP(N)-2010, UWMSP-SEL(F)-2010, UWMSP-SEL(G)-2010, UWMSP-SEL(K)-2010, UWMSP-SEL(L)-2010, UWMSP-SEL(N)-2010.

6 If an insured moves out of the service area, they will no longer have coverage and will have the opportunity to purchase any Medicare Supplement policy with comparable or lesser benefits offered by the insurer or Medicare Supplement / Select plans A, B, C or F from any insurer, within 63 days of termination.

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.

I understand that the Medicare Supplement Underwritten Application PDF document will not open until I have first opened the Medicare Supplement Underwritten Combo Outline of Coverage and Choosing a Medigap Policy: A Guide to Health for People with Medicare PDF documents.


TXWEB1061 - Rev 07/11

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