Senior Security Medicare Select Program

Security Health Plan's Senior Security Medicare Select program provides supplemental coverage for those who qualify for Medicare. Read the selections below to learn more about Senior Security Medicare Select:

• For Better Coverage of Your Health Care Costs
• Medicare Select Policy *
• Senior Security Premium Information *

Forms

• Authorization to Disclose Protected Health Information for Enrollment and Related Purposes (150 KB) - Last Revised: 07/31/07
  
• Application for Medicare Select Insurance (274 KB) - Last Revised: 08/26/04
  
• Application Addendum (226 KB) - Last Revised: 08/26/04
  
• Notice to Applicant (226 KB) - Last Revised: 08/26/04
  
• Medicare Select Acknowledgement of Receipt (201 KB) - Last Revised: 08/26/04
  
• Insurance Disclosure Form (271 KB) - Last Revised: 07/21/10
  

• Application Addendum (226 KB) - Last Revised: 08/26/04
  
• Application for Medicare Select Insurance (274 KB) - Last Revised: 08/26/04
  
• Authorization to Use and Disclose Protected Health Information for Enrollment and Related Purposes (89 KB) - Last Revised: 07/31/07
  
• Health Statement (279 KB) - Last Revised: 07/21/10
  
• Insurance Underwriting Information (231 KB) - Last Revised: 03/13/08
  
• Medicare Select Acknowledgement of Receipt (201 KB) - Last Revised: 08/26/04
  
• Notice to Applicant (226 KB) - Last Revised: 08/26/04
  
• Patient Signature on File for Medicare Claims (204 KB) - Last Revised:
  
• Insurance Disclosure Form (271 KB) - Last Revised: 07/21/10
  
• Automatic Premium Payment Plan (877 KB) - Last Revised: 08/07/10
  

* PDF document format