Medicare Supplement Plan Sample Contracts

EVIDENCE OF COVERAGE AND HEALTH SERVICE AGREEMENT
Medicare Supplement Plan • October 5th, 2022

This Evidence of Coverage and Health Service Agreement (“Agreement”) is issued by California Physi- cians’ Service dba Blue Shield of California ("Blue Shield"), a health care service plan, to the Subscriber whose name, group number, Subscriber identification number, and Effective Date shall appear on his or her identification card.

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EVIDENCE OF COVERAGE AND HEALTH SERVICE AGREEMENT
Medicare Supplement Plan • December 1st, 2014

This Evidence of Coverage and Health Service Agreement (“Agreement”) is issued by California Physi- cians’ Service dba Blue Shield of California ("Blue Shield"), a health care service plan, to the Subscriber whose name, group number, Subscriber identification number and Effective Date shall appear on his or her identification card.

Sample 1Sample 2
EVIDENCE OF COVERAGE AND HEALTH SERVICE AGREEMENT
Medicare Supplement Plan • December 13th, 2024

This Evidence of Coverage and Health Service Agreement (“Agreement”) is issued by California Physi- cians’ Service dba Blue Shield of California ("Blue Shield"), a health care service plan, to the Subscriber whose name, group number, Subscriber identification number, and Effective Date shall appear on his or her identification card.

Sample 1
EVIDENCE OF COVERAGE AND HEALTH SERVICE AGREEMENT
Medicare Supplement Plan • December 13th, 2024

This Evidence of Coverage and Health Service Agreement (“Agreement”) is issued by California Physi- cians’ Service dba Blue Shield of California ("Blue Shield"), a health care service plan, to the Subscriber whose name, group number, Subscriber identification number and Effective Date shall appear on his or her identification card.

Sample 1
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