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Forms

For Individual and Family Plan Members

Account Management Forms

• ACO Consent Opt-Out Form (applies only to Engage by Medica, North Memorial Acclaim, Ridgeview Distinct and Altru Prime by Medica members) – (PDF)
• Authorization to Disclose Protected Health Information (PDF)
• Premium Payment Options (PDF)
• Continuity of care request (PDF)
• Policy termination (PDF)
  If you enrolled through the federal marketplace or MNsure, you must contact the federal marketplace or MNsure to terminate your policy.
• Travel Reimbursement Form (PDF)

Medica ID Card Request Form

• Online ID card request form

Name and Address Change Form

• 2020 Iowa name and address change form (PDF)
• 2020 Kansas name and address change form (PDF)
• 2020 Minnesota name and address change form (PDF)
• 2020 Missouri name and address change form (PDF)
• 2020 Nebraska name and address change form (PDF)
• 2020 North Dakota name and address change form (PDF)
• 2020 Oklahoma name and address change form (PDF)
• 2020 Wisconsin name and address change form (PDF)