Downloadable Forms for Medicare Products

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 #
54226.0711	Medicare Supplement Underwritten Application	TX-MS-App-UW-2011-R1
54876.0811 TX	Medicare Supplement Guaranteed Issue Application	TX-MS-App-GI-2011-R1
30484.1111	Under Age 65 Disability Application	MSP-APP/DISA-D
30310.1111	Supplement to Your Application for Coverage (must accompany Disability Application)	MSP-SUP-APP-5
Stock # / Date	Outlines of Coverage	Texas Form #
55581.1214 TX	Medicare Supplement Outline of Coverage – Underwritten Combo	UWMSP-OC-CDP-2
55588.1214 TX	Medicare Supplement Outline of Coverage – Guaranteed Issue Combo	GIMSP-OC-CP-2
55587.1214 TX	Medicare Supplement Under Age 65 Disability Outline of Coverage	MSP-OC/DIS(A) Rev.6-12
Stock # / Date	Miscellaneous Forms	Texas Form #
730621.0915	Medicare Supplement ezBlue Payment Option Authorization Agreement	N/A
56085.0712	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
54205.0112	Medicare Supplement Sales Pack	MS COMPROUW Rev4
51180.0413 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.