Forms and Resources

This page is a one-stop shop to all things related to forms associated with Farm Bureau Health Plans. You can download and print prescription claims forms, change of coverage forms, and more.

Outline of Medicare Supplement Coverage

These charts show the benefits included in each of the standard Medicare Supplement Insurance plans. Every company must make available Plan A. Some of the other plans may not be available from every company.

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Medical request form (age 0-2 months)

This is a request form for any type of medical records that need to be requested for newborns through two months of age.

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Medical Request Form (Age 3-25 months)

This is a request form for any type of medical records that need to be requested for children 3-25 months old.

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Medical request form (age 40 and older)

This is a request form for any type of medical records that need to be requested for adults aged 40 or older.

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Notice to Applicant Regarding replacement of Medicare Supplement Insurance or Medicare Advantage

If you have a current Medicare Supplement or Medicare Advantage insurance and are replacing it with a Farm Bureau Health Plans Medicare Supplement, please complete this form.

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Under 65 Health Coverage Claim Form

Most providers will file health care claims for you. However, should you need to file a claim, please complete this form.

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Medicare Supplement Subscriber Health Care Claim Form

Most providers will file health care claims for you. However, should you need to file a claim, please complete this form.

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Precription Drug Claim Form

To file prescription drug claims for out of network pharmacies, complete this form and attach your prescription receipt or a print-out of your prescriptions signed by your pharmacist. All in-network claims will be filed electronically. 

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Questions or complaints

This resource includes instructions on how to submit questions and complaints regarding your policy or coverage.

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Personal Representative Designation

Your completion of this form allows you to designate someone as your personal representative on your Farm Bureau Health Plans coverage.

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Bank Draft Authorization Form (Under 65)

If you need to change your bank information for your monthly premium payment and you are under the age of 65, complete this form, attach a voided check and mail both to Farm Bureau Health Plans.

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Bank Draft Authorization Form (Over 65)

If you need to change your bank information for your monthly premium payment and you are over the age of 65, complete this form, attach a voided check and mail both to Farm Bureau Health Plans.

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Medicare Supplement Plan Selection Form

This form is for a current Kansas Farm Bureau Health Plans subscriber who is requesting to transition into a KFBHP Medicare Supplement Plan.

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Medicare Supplement Change Form

This form is for any type of plan change for an existing Farm Bureau Health Plans Medicare Supplement in regards to plan drops or upgrades. 

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Other Insurance Form

You should always keep Farm Bureau Health Plans informed of other insurance that you and your dependents may have as Farm Bureau Health Plans coverage contains a coordination of benefits provision. Complete this form and mail it to Farm Bureau Health Plans when you obtain other insurance.

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Under 65 Change Form

This form allows you to make changes to your current coverage if you are under 65.

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Cancellation Form for Members Under 65

Please complete this form if cancelling your coverage with Farm Bureau Health Plans and you are under 65.

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Change Form for Members Over 65

This form allows you to make changes to your current coverage if you are over 65.

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Cancellation Form for Members Over 65

Please complete this form if cancelling your coverage with Farm Bureau Health Plans and you are over 65.

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Forms for Underwriting Reconsideration

Request for Reconsideration of Benefit Exclusion Rider

This form is for you to complete when submitting a request for reconsideration of a benefit exclusion rider that has been placed on you or any dependents. Please use one form per rider being reviewed.

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Request for Reconsideration of Declined Coverage

This form is for you to complete when submitting a request for reconsideration of declined coverage for you or any dependents.

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Request for Reconsideration of Rate

This form is for you to complete when submitting a request for reconsideration of your rate for coverage.

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