Application / Forms
- Review the two benefit plan options carefully.
- Select the plan that is best for you. (The $2,500 deductible plan has the lowest premiums.)
- Review the premium rate chart to determine your monthly premium.
- Fill out the application completely.
- 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.
- Sign and date your application.
- 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-WA
PO Box 1090
Great Bend, Kansas 67530
2013 Enrollment Packet (includes plan information, rates and application)
2013 Application (application form only)
Prescription Drug Claim Form
Automatic Bank Withdrawal Authorization
Tobacco Use Affidavit Form
Enrollee Change Form
Authorization to Release Information Form
Los documentos en espaņol
Folleto de PCIP-WA
Solicitud de cobertura