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