All of the forms listed below are in PDF format which allows you to view them electronically on most computers. The Adobe Acrobat reader is required to view and print PDF files. If you do not have the reader, click here to download free of charge.

Applications

2010 Application

• KHIA Plan Application and Description

2009 Application

• KHIA Plan Application and Description

Premiums

KHIA Premium Rates Plan (Eff. Jan. 1, 2010)

• Premiums - Tobacco User
• Premiums - Non-Tobacco User

KHIA Premium Rates Plan (Eff. Jan. 1, 2009)

• Premiums - Tobacco User
• Premiums - Non-Tobacco User

Policies

• KHIA Policy (Eff. Jan. 1, 2009)
• KHIA Policy (Eff. Jan. 1, 2008)
• KHIA Policy (Eff. Jan. 1, 2007)

Forms

• Automatic Bank Withdrawal Authorization
• Member Change Form
• Personal Representative Form - used to provide permission to the health plan to release information on an ongoing basis to an individual acting as the member's "personal representative"
• Claim Form Non-Medicare

Outline of Coverage

• Outline of Coverage

Survey for Kansas Health Insurance Association.

• Frequently Asked Questions

Misc.

• KHIA Privacy Notice