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

747876.0122

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 May 1, 2022

 

 TXMSAPPDISA Rev. 01/22

47871.0122

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 May 1, 2022.

TXMSAPP Rev. 01/22

TBA

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 May 1, 2022.

TBA

747871.0122

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 May 1, 2022.

TXMSAPP Rev. 01/22

TBA

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 May 1, 2022.

TBA

747871.0122

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 May 1, 2022.

TXMSAPP Rev. 01/22

TBA

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 May 1, 2022.

TBA

747871.0122

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 May 1, 2022.

TXMSAPP Rev. 01/22

TBA

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 May 1, 2022.

TBA

747871.0122

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 May 1, 2022.

TXMSAPP Rev. 01/22

TBA

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 May 1, 2022.

TBA

747871.0122

Medicare Supplement Application – Med-Select Rating Area 4
Use this application when applying for Medicare Supplement Coverage in Rating Area 4 for an effective date on or after May 1, 2022.

TXMSAPP Rev. 01/22

TBA

Medicare Supplement Application – Med-Select 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 May 1, 2022.

TBA

Enrollment Forms and Change Forms

Stock # / Date

Enrollment Forms and Change Forms

Texas Form #

748218.1221 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

752721.1221 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, 2021.

MS-OOC-A1-STND Rev. 10/19

748036.1221 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

755504.1221 TX

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.

MS-OOC-A1-CMB

748386.1221 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

752723.1221 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, 2021.

MS-OOC-A2-STND Rev. 10/19

748382.1221 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

755505.1221 TX

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.

MS-OOC-A2-CMB

748388.1221 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

752725.1221 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, 2021.

MS-OOC-A4-STND Rev. 10/19

752725.1221 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

755507.1221 TX

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.

MS-OOC-A4-CMB

748293.0122 TX

Medicare Supplement Under Age 65 Disability Outline of Coverage

Use this outline of coverage when applying for Medicare Supplement Coverage with an Effective Date on or after May 1, 2022.

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) 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 #
729688.0220 Medicare Supplement Decision Guide Reader TXMSDG20
51180.0419 Medicare Select Network Hospital Listing N/A