Medicare Supplement Forms
Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Texas. To access more product information and sales resources, please log in to Blue Access for Producers.
The forms below are available as PDF files. Just click on the appropriate form, fill out the form and mail it in. You will need the Adobe® Reader® to view the following forms. Download this free of charge at Adobe's site . You can also visit our section on how to download a PDF file for additional information.
|Stock # / Date||Enrollment Forms||Texas Form #|
|54226.1115 TX||Medicare Supplement Underwritten Application||TX-MS-APP-UW-2015-R2|
|54876.0811 TX||Medicare Supplement Guaranteed Issue Application||TX-MS-App-GI-2011-R1|
|30484.1111||Under Age 65 Disability Application||MSP-APP/DISA-D|
|30310.1111||Supplement to Your Application for Coverage (must accompany Disability Application)||MSP-SUP-APP-5|
|Stock # / Date||Outlines of Coverage||Texas Form #|
|55581.0417 TX||Medicare Supplement Outline of Coverage – Underwritten Combo
Use this outline of coverage when applying for an Underwritten 2017 Medicare Supplement plan.
|55581.0416||Medicare Supplement Outline of Coverage – Underwritten Combo
Use this outline of coverage when applying for an Underwritten 2016 Medicare Supplement plan.
|55584.0417 TX||Medicare Supplement Standard Outline of Coverage
Use this outline of coverage when applying for a Guaranteed Issue 2017 Medicare Supplement plan.
|55587.0417||Medicare Supplement Under Age 65 Disability Outline of Coverage
Use this outline of coverage when applying for an U65 Disability 2017 Medicare Supplement plan.
|55587.0416||Medicare Supplement Under Age 65 Disability Outline of Coverage
Use this outline of coverage when applying for an U65 Disability 2016 Medicare Supplement plan.
|Stock # / Date||Miscellaneous Forms||Texas Form #|
|31752.0311||ezBlue Payment Option Authorization Agreement||N/A|
|56085.0712||Medicare Supplement List Bill||N/A|
|30029.0911||Medicare Supplement Notice of Replacement||TX-MS-NOR-2011-R1|
|N/A||Standard Authorization Form and other HIPAA Privacy Forms||N/A|
|Stock # / Date||Other Plan Information||Texas Form #|
|N/A||Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare||N/A|
|54205.0112||Medicare Supplement Sales Pack||MS COMPROUW Rev4|
|51180.0413 TX||Medicare Select Network Hospital Listing||N/A|
Other Medicare Products
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