Forms & Resources – Texas Farm Bureau Health Plans

Forms & Resourcescraig2023-06-30T12:30:00-06:00

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)

Alternative Plan Selection-Transfer-Change Form (Under 65)

Bank Draft Authorization Form (Over 65)

Bank Draft Authorization Form (Under 65)

Certification of Intent To Adopt and Financial Responsibility

Grievance Procedures

Medicare Supplement Cancellation Form

Medicare Supplement Change Form

Individual Conversion Medicare Supplement Complaint Form

Group 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)

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Copyright © 2023 Texas Farm Bureau Health Plans. All Rights Reserved.

Medicare Supplements are insured by Members Health Insurance Company, Columbia, TN. Not connected with or endorsed by the United States government or the federal Medicare program. This is a solicitation of insurance. A representative of Members Health Insurance Company may contact you. You must be a member of Texas Farm Bureau to enroll in Texas Farm Bureau Medicare Supplement Plans.

MH-TXG-CERTA-FL21-128; MH-TXG-CERTD-FL21-129; MH-TXG-CERTG-FL21-130; MH-TXG-CERTN-FL21-131

Individual & Family Plans and Dental & Vision Plans are underwritten and provided by Texas Farm Bureau Health Plans and authorized under Tex. Ins. Code § 1682 as Nonprofit Agricultural Organization Health Benefits. Coverage is not considered insurance and is not provided by an insurance company.

MH-TX-CM-FL21-350