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Get Application For Coverage With Health History

Paul, MN 55164-0560 (651) 662-8000 (888) 878-0139 TTY (888) 878-0137 MEDICARE SUPPLEMENT/ MEDICARE SELECT PLAN Application for Coverage with Health History How to complete this application: 1. You must have both Medicare Part A and Part B to qualify for this coverage. Please include a copy of your Medicare ID card with this application. 2. Please print and use a ball point pen in black or blue ink. Applications completed in pencil are not acceptable. Please answer all questions completely. 3.

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How to fill out the Application For Coverage With Health History online

The Application For Coverage With Health History is essential for those seeking Medicare Supplement or Medicare Select policies. This guide provides clear, step-by-step instructions to help users fill out the form effectively and efficiently.

Follow the steps to complete your application accurately.

  1. Use the ‘Get Form’ button to obtain the application form and open it in your preferred editor.
  2. Complete Section I: Provide personal details such as your name, home address, contact number, birth date, and social security number accurately.
  3. Make sure to check if you are enrolled in both Medicare Part A and Part B. Attach a copy of your Medicare ID card to your application.
  4. Fill out the necessary health history questions in Section II to the best of your knowledge. Be prepared to disclose any pre-existing conditions or treatments.
  5. In Section III, indicate your tobacco use and answer other specific health-related questions. If you are eligible for guaranteed issue, be aware that you may skip this section.
  6. Select the Medicare plan you wish to apply for in Section II and specify your preferred payment method in Section I, item #10.
  7. Sign and date your application to certify that all information provided is complete and accurate. Retain a copy for your records.
  8. Submit your application to Blue Cross and Blue Shield of Minnesota. Allow 3-6 weeks for processing, during which you will receive your member identification card.

Complete your application for coverage online today to ensure your health needs are met.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232