By clicking on a specific form name (highlighted and underlined), you can review and print the form or the detailed informational pamphlet.

New Applicant Enrollment Froms
All three of the following forms must be completed and submiteed to enroll in the MHIP.

Application Missouri

Application Kansas City

Application Checklist

Other Forms

Claim Form
This form is to be used when filing for any medical services rendered by a non-PPO or non-network provider. There is not a separate claim form available for Blue Cross and Blue Shield of Kansas City so you can use the same form but it must be mailed to: Blue Cross and Blue Shield of Kansas City, P.O. Box 419169, Kansas City, MO, 64179-01 47.

Enrollee Change Form
This form is to be used by persons currently enrolled in the MHIP to change existing information such as Contact, Mailing Address, etc. It is to also be used when changing your deductible option plan choice during the MHIP's annual open enrollment that occurs in November of each year.

Benefit Summary
This document is the Plan Document whereas the "Benefit Brochure" is a more general summary. If there is any discrepancy between the Certificate and the Brochure, the Certificate supercedes.

Getting the Most from Your Prescription Benefit Program

Participating Pharmacies
This is a listing of the larger pharmacy chains and stores that participate in the MedTrak Services pharmacy network. If you fill your prescriptions at one of these pharmacies, you maximize the coverage and benefits available under the MHIP's prescription drug card program. For a complete listing of all participating pharmacies access the following link www.BuildingBetterHealth.com.

Save on Mail Service
This document describes how to use the mail-order program. Remember: If you purchase a 90-day supply through the mail-order program, your applicable copayment is tripled.

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