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Find your health insurance form

Find health insurance forms for your Medica individual or family health insurance plan.

Forms

For individual and family plan members

Account management forms

ACO Consent Opt-Out (applies only to Engage by Medica, North Memorial Acclaim, Ridgeview Distinct, and Altru Prime by Medica members) — (writeable PDF)
Authorization to Disclose Protected Health Information (PDF)
Continuity of Care Request (PDF)
Dental reimbursement (writeable PDF)
Policy Termination (writeable PDF)
Premium Payment Options (PDF)
Travel Reimbursement (writeable PDF)

If you enrolled through the federal marketplace or MNsure, you must contact the Health Insurance Marketplace or MNsure to terminate your policy.

Claim Forms

Medical claim form (PDF)
Pharmacy Claim Submission Form (PDF)

Medica ID card request form

Online ID Card Request

Name and address change forms

2024 Arizona name and address change (PDF)

2024 Iowa name and address change (PDF)

2024 Kansas name and address change (PDF)

2024 Minnesota name and address change (PDF)

2024 Missouri name and address change (PDF)

2024 Nebraska name and address change (PDF) 

2024 North Dakota name and address change (PDF)

2024 Wisconsin name and address change (PDF)

Plan documents

View your summary of benefits and coverage (SBC) and policy of coverage documents
Get documents

 Order plan documents

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