Primary Care & Home Clinic Change Request

You may change your primary care clinic by notifying Medica at least 10 days before the first day of the next month. That is the date the change will take effect. Please refer to your Certificate of Coverage for more information on primary care clinic transfers. You may also contact Medica Customer Service for assistance.

* Required Field


Member Information

* Group/Policy number:  
Five to nine charaters
* Member/Subscriber ID:
Nine digits
* First Name:  
* Last Name:  
* Daytime Phone #:
   Email Address:  

Clinic Information

* Current Clinic Name:
* Current Clinic ID:
Eleven digits
* New Clinic Name:  
* New Clinic ID:
Eleven digits
* Effective Date:
MM/DD/YYYY

Dependent Information
Enter your dependent's changes below (if any). If a dependent is entered, all fields are required for that dependent.

Name Current Clinic Name Current Clinic ID New Clinic Name New Clinic ID Effective Date

     

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