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) |