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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. |
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| 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. |
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| 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. |
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| 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 |
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| 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 |
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| 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 |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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 |