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.
FAQs
We've compiled a list of frequently asked questions and answers about our services.
Questions?
We're here to help! Call us toll-free at 866-544-2232 or contact your local Farm Bureau Financial Services agent.
Looking for an Agent?
Farm Bureau Financial Services agents are equipped and ready to provide you a variety of health care coverage options.
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.
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.
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.
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.
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.
Grievance Procedure
This resource explains the grievance procedure used by Nebraska Farm Bureau Health Plans. If you would like to file a grievance, please use this form.
Personal Representative Designation
Your completion of this form allows you to designate someone as your personal representative on your Farm Bureau Health Plans coverage.
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.
Under 65 Change Form
This form allows you to make changes to your current coverage if you are under 65. The form has the functionality for a digital signature, but it must be opened in Acrobat (not the web browser) for it to work correctly.
Cancellation Form for Members Under 65
Please complete this form if cancelling your coverage with Farm Bureau Health Plans and you are under 65.
Payor Revoking Authorization Form
This form allows an employer to let KFB Health Plans know an employee/client of KFB Health Plans no longer works for them and the client will take over the health plan payment.
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.
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.
Request for Reconsideration of Rate
This form is for you to complete when submitting a request for reconsideration of your rate for coverage.
Request for Reconsideration of Tobacco Rate
This form is for you to complete when submitting a request for reconsideration of tobacco rate for coverage.
Next Step
Ready to Enroll?
If you already know what coverage you need, and you're ready to sign-up for affordable and quality coverage, we're ready to help.