Supplement-65 Application - CareFirst BlueCross BlueShield 2026

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Click ‘Get Form’ to open the Supplement-65 Application in the editor.
Begin by filling out Section 1, Applicant Information. Provide your personal details such as name, address, and Social Security number. Ensure all information is printed clearly.
In Section 1B, select the Supplement-65 Plan you wish to apply for by checking only one option. This is crucial for processing your application correctly.
Proceed to Section 2 and enter your Medicare coverage information as it appears on your Medicare card. This includes your Health Insurance Claim Number and effective dates for both Part A and Part B.
Complete Section 3 regarding eligibility by answering the questions truthfully. If applicable, provide documentation for guaranteed issue eligibility in Section 9.
Review all sections carefully before signing on page 11. Make sure there are no errors or omissions that could delay processing.

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