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Member Forms
The Forms option allows you to create and submit Medica health care forms electronically or to print them for submission through the mail. You can also request a new ID card.
Electronic Forms
(To fill in and submit electronically)
ID Card Request
Change My Primary Care / Home Clinic
Printable Forms
(To print and mail)
Statement of Claims
Prescription Claim Print Form
Medica Direct Forms -- Members Through Work
Medica Direct: FSA Claim Form
Medica Direct: Direct Deposit Form
Individual and Family
Automated Payment Plan (ACH)
Change Form for Medica Direct HSA
SM
& Medica Direct Value
SM
Change Form for Medica Solo
SM
& Medica Encore
SM
Medica Encore Eyewear Claim Form
Medica Solo
SM
Eyewear Claim Form
Policy Termination Form
Transplant Program
Travel & Lodging Expense Reimbursement Form