PCIP-KS
PO BOX 1090
Great Bend, KS 67530
1-877-505-0511

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Click Here to request your enrollee login to check claims and benefits, change address or send a question to Customer Service.

Application / Forms

Application Process

1. Click Here to download an application.
2. Call Customer Service for a premium rate quote. (1-877-505-0511)
3. Review the benefit plan carefully.
4. Fill out the application completely.
5. Attach copies of all required documentation, including evidence of your pre-existing condition or a letter of coverage denial 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 days.)  Fax number: 1-877-505-0522.

Mail application to:   PCIP-KS
                                  PO Box 1090
                                  2015 16th St.
                                  Great Bend, Kansas 67530

Application/Forms
Application
Automatic Bank Withdrawal Authorization
Authorization to Release Information Form