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Downloadable Forms for Medicare Supplement


Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Texas (BCBSTX). To access more downloadable forms, please log in to Blue Access for Producers.

To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.

Enrollment Forms

Form Name Digital Form Download

Medicare Supplement Underwritten Application

N/A download form Word Document

Medicare Supplement Guaranteed Issue Application

N/A download form Word Document

Medicare Supplement Under Age 65 Disability Application

N/A download form Word Document

Supplement to Your Application for Coverage – must accompany Disability Application

N/A download form Word Document

 

Outlines of Coverage

Outline Name Digital Form Download

Medicare Supplement Outline of Coverage (Underwritten Combo) – Use this outline of coverage when applying for an Underwritten 2017 Medicare Supplement plan.

N/A download outline Acrobat PDF

Medicare Supplement Standard Outline of Coverage – Use this outline of coverage when applying for a Guaranteed Issue 2017 Medicare Supplement plan.

N/A download outline Acrobat PDF

Medicare Supplement Under Age 65 Disability Outline of Coverage – Use this outline of coverage when applying for an U65 Disability 2017 Medicare Supplement plan.

N/A download outline Acrobat PDF

 

Miscellaneous Forms

Form Name Digital Form Download

Medicare Supplement ezBlue Payment Option Authorization Agreement

N/A download form Acrobat PDF

Medicare Supplement List Bill

N/A download form Acrobat PDF

Medicare Supplement Notice of Replacement

N/A download form Acrobat PDF

 

Other Plan Information

Form Name Digital Form Download

Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare

N/A download guide Acrobat PDF

Medicare Supplement Sales Pack

N/A download pack Acrobat PDF

Medicare Select Network Hospital Listing

N/A download list Acrobat PDF

 

Legal / HIPAA Forms

Form Name Digital Form Download

Standard Authorization Form and other HIPAA Privacy Forms

N/A

N/A

 

Other Medicare Products

Thank you for your interest in Blue Medicare Rx (PDP). Please remember that before a producer can market Blue MedicareRx (PDP), order and/or download marketing materials, they must complete our training and certification/re-certification program . Please contact us for more information.