Teacher Retiree Over 65 Medical Form - Office Of The State Treasurer (Page 2 of 2) in pdf

Teacher Retiree Over 65 Medical Form - Office Of The State Treasurer Page 2

Group Name

Group No. (including section)

What kind of policy?

(3) If the answer to question 1 or 2 is yes, do you intend to replace these medical or health policies with this policy?

c Yes

c No

(4) Are you covered by Medicaid?

c Yes

c No

Section 6: Information Required by Law

(1) You only need one Medicare supplement policy.

(2) If you are 65 or older, you may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.

(3) The benefits and premiums under your Medicare supplement policy will be suspended during your entitlement to benefits under Medicaid

for 24 months. You must request this suspension within 50 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid,

your policy will be reinstituted if requested.

(4) Counseling services may be available to provide advice concerning your purchase of Medicare supplement insurance and concerning Medicaid.

Section 7: Signature

I certify that the statements on this application and all information furnished by me are true and complete to the best of my knowledge.

I authorize any health care provider to disclose to Blue Cross and Blue Shield of Vermont, or its designated agent, any information acquired in

connection with any past or future care or treatment. I understand that no right whatsoever is created by this application and that the same

shall not be considered accepted unless and until the contract is actually issued by Blue Cross and Blue Shield of Vermont.

Subscribers Signature

Date

____ / ____ / ____

Effective Date

FOR OFFICE USE ONLY

____ / ____ / ____

280.285 (08/2014)

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Teacher Retiree Over 65 Medical Form - Office Of The State Treasurer Page 2