ID Card Request

** You must be at least 18 years of age or older to request a replacement ID card.

This information is used for verification purposes only. Materials will be mailed to the address on file in the eligibility system.

* First Name:
Middle Name:
* Last Name:
* Group/Policy Number:
(NOT the Payer ID)		 Five or Six characters.
* ID Number: Nine digits.
* Address Line 1:
Address Line 2:
* City: e.g. Saint Paul, Minneapolis, etc.
* State:
* Zip Code:
* Quantity Requested:
  
To request a new ID card, complete the form and select Submit to return the form electronically to Medica® Health Plans. To return to the Forms Menu, select Cancel. You should receive your new ID card(s) within ten business days.
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