ACHIA-FED
PO BOX 1090
Great Bend, KS 67530
1-877-505-0510

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Application / Forms

Application Process

1. Review the benefit plan option carefully.
2. Review the premium rate chart to determine your monthly premium based on your age.
3. Fill out the application completely.
4. 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.
5. Sign and date your application. 
6. 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 application to:   ACHIA-FED
                                  PO Box 1090
                                  2015 16th St.
                                  Great Bend, Kansas 67530

Application / Forms
Application
Authorization Agreement For Preauthorized Payments form
Authorization to Release Information form