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.
|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|
|Transition of Care Form|
|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|
Members can use the claim forms for services rendered by in-area or out-of-area non-participating providers. Participating providers are responsible for filing claims for their services. Claim forms should not be used for services rendered through any discount dental or vision program or for the options program for alternative therapies. The discount is applied by the provider at the time of service for such programs.
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