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, 2022.
TXMSAPPDISA
747871.0720 Medicare Supplement Application – Standard Rating Area 1
Use this application when applying for Medicare Supplement Coverage in Rating Area 1 for an effective date on or after January 1, 2023.

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 for an effective date on or after January 1, 2023.
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 for an effective date on or after January 1, 2023.
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 for an effective date on or after January 1, 2023.
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 for an effective date on or after January 1, 2023.
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 for an effective date on or after January 1, 2023.
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 for an effective date on or after January 1, 2023.
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 for an effective date on or after January 1, 2023.
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 for an effective date on or after January 1, 2023.
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 for an effective date on or after January 1, 2023.
TXMSAPP Rev. 0221
747871.0720 Medicare Supplement Application – Med-Selec Rating Area 4 
Use this application when applying for Medicare Supplement Coverage in Rating Area 4 for an effective date on or after January 1, 2023.
TXMSAPP Rev. 0221
752569.0121 Medicare Supplement Application – Med-Selec Rating Area 4 (Spanish Version)
Use this application when applying for Medicare Supplement Coverage in Rating Area 4 for an effective date on or after January 1, 2023.
TXMSAPP Rev. 0221
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, 2022.
TXMSAPPDISA
747871.0720 Medicare Supplement Application – Standard Rating Area 1
Use this application when applying for Medicare Supplement Coverage in Rating Area 1 for an effective date on or after January 1, 2022.

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 for an effective date on or after January 1, 2022..
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 for an effective date on or after January 1, 2022.
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 for an effective date on or after January 1, 2022.
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 for an effective date on or after January 1, 2022.
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 for an effective date on or after January 1, 2022.
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 for an effective date on or after January 1, 2022.
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 for an effective date on or after January 1, 2022.
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 for an effective date on or after January 1, 2022.
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 for an effective date on or after January 1, 2022.
TXMSAPP Rev. 0221
747871.0720 Medicare Supplement Application – Med-Selec Rating Area 4 
Use this application when applying for Medicare Supplement Coverage in Rating Area 4 for an effective date on or after January 1, 2022.
TXMSAPP Rev. 0221
752569.0121 Medicare Supplement Application – Med-Selec Rating Area 4 (Spanish Version)
Use this application when applying for Medicare Supplement Coverage in Rating Area 4 for an effective date on or after January 1, 2022.

Enrollment Forms and Change Forms

  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 January 1, 2023.
 
  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 January 1, 2023.
 
  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 January 1, 2023.
 
  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 January 1, 2023
 
  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 January 1, 2023
 
  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 January 1, 2023
 
  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 January 1, 2023.
 
  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 January 1, 2023.
 
  Medicare Supplement Outline of Coverage – Standard Rating Area 4
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 2 with an Effective Date on or after January 1, 2023.
 
  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 2 with an Effective Date on or after January 1, 2023.
 
  Medicare Supplement Outline of Coverage – Med Select Rating Area 4
Use this outline of coverage when applying for Medicare Supplement Coverage in Rating Area 2 with an Effective Date on or after January 1, 2023.
 
  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 2 with an Effective Date on or after January 1, 2023.
 
784293.0122 TX Medicare Supplement Under Age 65 Disability Outline of Coverage
TBA
MS-OOC-DIS Rev. 01/22
748218.0122 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, 2022.
MS-OOC-A1-STND Rev. 01/22
  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, 2022.
 
748036.0122 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, 2022.
MS-OOC-A1-CMB 01/22
  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, 2022.
 
748386.0122 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, 2022.
MS-OOC-A2-STND Rev. 01/22
  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, 2022.
 
748382.0122 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, 2022.
MS-OOC-A2-CMB 01/22
  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, 2022.
 
748388.0122 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, 2022
MS-OOC-A4-STND Rev. 01/22
  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, 2022.
 
748384.0122 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, 2022.
MS-OOC-A4-CMB 01/22
  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, 2022.
 

Medicare Secondary Payer (MSP) Forms and Information

Stock # / Date MSP Form and Information Texas Form #
753075.0421 Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions N/A
21092.060 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 #
729688.0220 Medicare Supplement Decision Guide Reader TXMSDG20
51180.0419 Medicare Select Network Hospital Listing N/A