Medicare Supplement Forms
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| 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 |
| Stock # / Date | Enrollment Forms and Change Forms | Texas Form # |
| 748218.0220 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, 2020. |
MS-OOC-A1-STND Rev. 10/19 |
| 752721.0220 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, 2020. |
MS-OOC-A1-STND Rev. 10/19 |
| 748386.0220 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, 2020. |
MS-OOC-A2-STND Rev. 10/19 |
| 752723.0220 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, 2020. |
MS-OOC-A2-STND Rev. 10/19 |
| 748388.0220 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, 2020. |
MS-OOC-A4-STND Rev. 10/19 |
| 752725.0220 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, 2020. |
MS-OOC-A4-STND Rev. 10/19 |
| 748218.0321 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 |
| TBA | 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. |
TBA |
| 748036.0321 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 |
| TBA | 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. |
TBA |
| 748386.0321 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 |
| TBA | 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. |
TBA |
| 748382.0321 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 |
| TBA | 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. |
TBA |
| 748388.0321 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 |
| TBA | 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. |
TBA |
| 748384.0321 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 |
| TBA | 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. |
TBA |
| 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 |
| Stock # / Date | Other Plan Information | Texas Form # |
| N/A | Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare |
N/A |
| 729688.0220 | Medicare Supplement Decision Guide Reader |
TXMSDG20 |
| 51180.0419 | Medicare Select Network Hospital Listing |
N/A |
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