FORMS & RESOURCES

Download and print applications, prescription claims forms, change of coverage forms and more.

Forms Used with a New Application

Authorization for Release of Protected Health Information (PHI)
Notice to Applicant Regarding Replacement of Medicare Supplement Insurance
Request for Medical 0-2 months
Request for Medical 3-25 months
Request for Medical Over 40

Claims Forms

Texas Medicare Supplement Subscriber Health Care Claim Form
Medical and DentalVision Claim Form (Under 65)
Prescription Drug Claim Form (Under 65)

Forms For Underwriting Reconsideration

Reconsideration of Decline
Reconsideration of Rate
Reconsideration of Rider
Reconsideration of Tobacco Rate (Under 65)

Other Useful Forms

Alternative Plan Selection-Transfer-Change Form (Over 65)
Bank Draft Authorization Form (Over 65)
Bank Draft Authorization Form (Under 65)
Certification of Intent To Adopt and Financial Responsibility
Grievance Form
Grievance Procedures
Medicare Supplement Cancellation Form
Medicare Supplement Change Form
Medicare Supplement Complaint Notice
Medicare Supplement Plan Selection Form
Other Insurance Form
Personal Representative Designation Form (Under 65)
Personal Representative Designation Form (Over 65)
Traditional Cancellation Form (Under 65)