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
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
(For residents of Maryland and D.C.)
Membership Change Form
(For residents of Virginia)