Medicare Supplement Plan

  • How to Complete Your Out-of-Network Claim Form (Senior Preferred members)
    Medical Claim
    Dental Claim
    BlueDental Prevention +1 Submission Form
    Pharmacy Compounded Medication Claim
  • Autopay Authorization
  • Medicare Supplement Application
  • Attestation Form
  • Confidential Information Release Form
    Confidential Information Release for HIV Form
    Accounting of PHI Disclosure Request Form
    Amendment to PHI Disclosure Request Form
    Authorized Representative Designation Form
    Non-Tobacco Use Affidavit Form
    Request for Protect Communications Form
    Request for Health Records Form
    Request to Restrict Health Records Form
    Privacy Complaint Form
    HIPAA Notice of Privacy Practices