X
We use cookies to ensure you get the best experience on our website. Cookie Policy 
OK

Forms

For employer provided health plan members

Choose the state where your company’s headquarters is located to find and print administrative forms.

Iowa

Large group forms

Enrollment/Change/Cancellation (PDF)
Enrollment/Change/Cancellation - Spanish (PDF)

Small group forms

Small Employer Group Application (PDF)
Enrollment/Change/Cancellation (PDF)
Enrollment/Change/Cancellation - Spanish (PDF)

Minnesota

Large group forms

Plans with a six-digit group number:
Enrollment/Change/Termination (PDF)
Plans with a five-digit group number:
Group Enrollment/Change/Cancellation (writeable PDF)
Group Enrollment/Change/Cancellation (Spanish) — (writeable PDF)
Plan Selection Change (PDF)
Scheduled Direct Debit Authorization for Groups (PDF)

Small group forms

Small Employer Group Application (writeable PDF)
Group Enroll/Change/Cancellation (writeable PDF)
Plan Selection Change (PDF)
Scheduled Direct Debit Authorization for Groups (PDF)
Small Group Enrollment/Change/Cancellation (Spanish) — (PDF)

Tips for employers

Group Enrollment/Change/Cancellation Form: Tips for Employers (PDF)
Medica Plan Selection Form: Tips for Employers (PDF)

Nebraska

Large group forms

Enrollment/Change/Cancellation (PDF)
Enrollment/Change/Cancellation - Spanish (PDF)

Small group forms

Small Employer Group Application (PDF)
Enrollment/Change/Cancellation (PDF)
Enrollment/Change/Cancellation - Spanish (PDF)

North Dakota

Large group forms

Plans with a six-digit group number:
Enrollment/Change/Termination (PDF)
Plans with a five-digit group number:
Group Enrollment/Change/Cancellation (writeable PDF)
Group Enrollment/Change/Cancellation - Spanish (writeable PDF)
Plan Selection Change (PDF)
Scheduled Direct Debit Authorization for Groups (PDF)

Small group forms

Small Employer Group Application (writeable PDF)
Group Enroll/Change/Cancellation (writeable PDF)
Plan Selection Change (PDF)
Scheduled Direct Debit Authorization for Groups (PDF)
Small Group Enrollment/Change/Cancellation (Spanish) — (PDF)

Tips for employers

Group Enrollment/Change/Cancellation Form: Tips for Employers (PDF)
Medica Plan Selection Form: Tips for Employers (PDF)

South Dakota

Large group forms

Plans with a six-digit group number:
Enrollment/Change/Termination (PDF)
Plans with a five-digit group number:
Group Enrollment/Change/Cancellation (writeable PDF)
Group Enrollment/Change/Cancellation (Spanish) — (writeable PDF)
Plan Selection Change (PDF)
Scheduled Direct Debit Authorization for Groups (PDF)

Small group form

Small Employer Group Application (writeable PDF)
Group Enroll/Change/Cancellation (writeable PDF)
Plan Selection Change (PDF)
Scheduled Direct Debit Authorization for Groups (PDF)
Small Group Enrollment/Change/Cancellation (Spanish) — (PDF)

Tips for employers

Group Enrollment/Change/Cancellation Form: Tips for Employers (PDF)
Medica Plan Selection Form: Tips for Employers (PDF)

Wisconsin

Large group forms

Plans with a six-digit group number:
Enrollment/Change/Termination (PDF)
Plans with a five-digit group number:
Group Enrollment/Change/Cancellation (writeable PDF)
Group Enrollment/Change/Cancellation (Spanish) — (writeable PDF)
Plan Selection Change (PDF)
Scheduled Direct Debit Authorization for Groups (PDF)

Small group forms

Small Employer Group Application (writeable PDF)
Group Enroll/Change/Cancellation (writeable PDF)
Plan Selection Change (PDF)
Scheduled Direct Debit Authorization for Groups (PDF)
Small Group Enrollment/Change/Cancellation (Spanish) — (PDF)

Tips for employers

Group Enrollment/Change/Cancellation Form: Tips for Employers (PDF)
Medica Plan Selection Form: Tips for Employers (PDF)