Other Forms

Bank Draft Agreement

Print a copy of the agreement.

Medicare Supplement members should send their Bank Draft Agreements to:

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

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

Medicare Supplement Appeals Form

Medicare Supplement Appeals Form