Application Process

1. Click Here to download an application.
2. Review the benefit plan carefully.
3. Review the premium rate chart to determine your monthly premium.
4. Fill out the application completely.
5. Attach copies of all required documentation, including evidence of your pre-existing condition, or a denial letter from an insurance company due to a pre-existing condition, or a letter of acceptance with a reduction or exclusion of coverage for your pre-existing condition.
6. Sign and date your application. 
7. Enclose a check for your applicable premium and mail your application and supporting documents to us at the address below.  (You may fax your application if originals and payment are sent by mail within 5 business days.)  Fax number: 1-877-505-0522.

Mail Applications to: HIPIOWA-FED PO Box 1090 2015 16th St. Great Bend, Kansas 67530

Application/forms Application Claim Form Automatic Bank Withdrawal Authorization Authorization to Release Information Form Tobacco Use Affidavit Form