Evidence of Coverage and Health Service AgreementMedicare Supplement Plan G • October 19th, 2023
This Evidence of Coverage and Health Service Agreement (“Agreement”) is issued by California Physicians’ 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.
Evidence of Coverage and Health Service AgreementMedicare Supplement Plan G • December 13th, 2021
This Evidence of Coverage and Health Service Agreement (“Agreement”) is issued by California Physicians’ 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 identi- fication card.
EVIDENCE OF COVERAGE AND HEALTH SERVICE AGREEMENTMedicare Supplement Plan G • April 28th, 2023
This Evidence of Coverage and Health Service Agreement (“Agreement”) is issued by California Physicians’ 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.
Group Medicare Supplement Plan G Washington Health Care AuthorityMedicare Supplement Plan G • August 31st, 2023
Please find enclosed • Outline of Medicare Supplement Coverage • Group Medicare Supplement Enrollment Application/Eligibility Attachment (see State Residents) • Automatic Funds Transfer Agreement (authorization for automatic payment program) • Notice to Applicant regarding replacement of Medicare Supplement Coverage • Release of information authorization form (only necessary of you would like to authorize another person to have access to your information) What’s next? Submit your completed application/eligibility attachment and any other information via• Fax to: 425-918-5278• Mail to:PO Box 327, MS 295Seattle, WA 98111
