Other Forms

Bank Draft Agreement

Print a copy of the Agreement.

Personal BluePlanSM members should send their Bank Draft Agreements to:

Personal BluePlan
P.O. Box 61153
Columbia, SC 29260-1153

Medicare Supplement members should send their Bank Draft Agreements to:

Consumer Products Business Unit
P.O. Box 100133
Columbia, SC 29202-3133

Medicare BlueSM, Medicare BlueSM Plus and Medicare BlueSM Private members should send their Bank Draft Agreements to:

Consumer Products Business Unit, Medicare Advantage
P.O. Box 100133
Columbia, SC 29202-3133

MedBlueSM Rx and MedBlueSM Rx Plus members should send their Bank Draft Agreements to:

MedBlue Rx or MedBlue Rx Plus
P.O. Box 100191
Columbia, SC 29202-3191

HIPAA Compliance Forms

Here are the Health Insurance Portability and Accountability Act (HIPAA) compliance forms. They have also been translated into Spanish.

Authorization To Disclose Protected Health Information For Underwriting
Autorización Para Revelar Información Protegida De Salud Para Aseguramiento

Authorization To Disclose Protected Health Information To A Third Party
Autorización Para Revelar Información Protegida De Salud A Terceros

Independent Contractors Receiving a 1099 Form

Businesses wishing to cover independent contractors must fill out the independent contractor coverage form. Once completed, please send the form to your Marketing Representative.

Underwriting Forms

Blood Pressure Questionnaire
Cholesterol Questionnaire
Request for Underwriting Opinion

Medicare Supplement Appeals Form

Medicare Supplement Appeals Form