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Report a screening

Tell us which screenings or tests you received more than three months ago or prior to becoming a Medica member. This information helps us keep your records up to date.

First name

Last name

Date of birth

Member ID number

Which screenings or tests did you complete? (Check all that apply.)

Breast cancer screening

When was the breast cancer screening done?

What provider ordered the breast cancer screening?

What is the name and address of that provider's clinic?

Colon cancer screening

When was the colon cancer screening done?

What provider ordered the colon cancer screening?

What is the name and address of that provider's clinic

Which colon cancer screening did you have?

Colonoscopy

Flexible sigmoidoscopy

CT colonography

FIT test (e.g. fecal occult blood test)

FIT-DNA test (e.g. Cologard)

Other (please specify)

What is the name of the colon cancer screening performed?

Diabetes eye

When was the diabetes eye screening done?

What provider order the diabetes eye screening?

What is the name and address of that provider's clinic

Diabetes A1c

When was the diabetes A1c screening done?

What provider ordered the diabetes A1c screening?

What is the name and address of that provider's clinic?

Diabetes nephropathy screening

When was the diabetes nephropathy screening done?

What provider ordered the diabetes nephropathy screening?

What is the name and address of that provider's clinic?

Other screening or test (procedure not listed)

What other screening or test did you complete?

When was the screening or test done?

What provider ordered this screening or test?

What is the name and address of that provider's clinic?

Attach a file

Medica DUAL Solution® and Medica AccessAbility Solution® Enhanced are health plans that contract with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in Medica DUAL Solution and Medica AccessAbility Solution Enhanced depends on contract renewal.

Last Updated: November 2023
Y0088_1000975_C
H2458_1000975 Accepted

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Closed Thursday 8 a.m. – 9 a.m. CT
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Please note: Hours may vary depending on the type of plan you have.

1-800-952-3455 (TTY: 711)

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