Medicare Supplemental/Medigap Medical Forms
If you need a form that is currently not available online, please call Member Services at the telephone number on your ID card.
Major Medical Claim |
International Claim Form
(For care received out of network area) |
Coordination of Benefits
(Update your information on My Account) |
Advanced Directive Information Sheet |
Maryland Advance Directive |
Continuity of Care - Members in a Maryland Based Plan (PDF) |
MedPlus Household Discount Request Form
For residents of Maryland who purchased a MedPlus Medigap plan with an effective date of August 1, 2016 or later. |
Reinstatement Request Form |
Plan Termination Form |
Membership Change Form |