Blue Access for Producers

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 #
54226.1017 TX Medicare Supplement Application  TX-MS-APP-UW-2015-R2
54876.0811 TX Medicare Supplement Guaranteed Issue Application  TX-MS-App-GI-2011-R1
30484.0218 Medicare Supplement Under Age 65 Disability Application  MSP-APP/DISA-D REV-0218
30310.1111 Supplement to Your Application for Coverage (must accompany Disability Application)  MSP-SUP-APP-5
Stock # / Date Outlines of Coverage Texas Form #
55581.0518 TX Medicare Supplement Outline of Coverage – Underwritten Combo 
Use this outline of coverage when applying for an Underwritten 2018 Medicare Supplement plan.
UWMSP-OC-CDP-3
55584.0518 TX Medicare Supplement Standard Outline of Coverage 
Use this outline of coverage when applying for a Guaranteed Issue 2018 Medicare Supplement plan.
UWMSP-OC-SD SB-2
55587.0518 Medicare Supplement Under Age 65 Disability Outline of Coverage 
Use this outline of coverage when applying for an U65 Disability 2018 Medicare Supplement plan.
MSP-OC/DIS(A) Rev.4-17
Stock # / Date Miscellaneous Forms Texas Form #
730621.0915 ezBlue Payment Option Authorization Agreement  N/A
56085.00615 TX 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
729688.0318 Medicare Supplement Decision Guide Reader  MS COMPROUW Rev4
51180.0817 TX Medicare Select Network Hospital Listing  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.

 

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