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Forms
For Medica Advantage Solution Members
Plan Management Forms
Claim and Reimbursement Forms
- Dental Reimbursement Form (PDF) – applies to Medica Advantage Solution (HMO, PPO, HMO-POS, HMO I-SNP), Medica Group Advantage Solution (PPO)
- Eyewear Reimbursement Form (PDF) – applies to Medica Advantage Solution (HMO, PPO, HMO-POS, HMO I-SNP), Medica Group Advantage Solution (PPO)
- Hearing Aid Reimbursement Form (PDF) – applies to Medica Advantage Solution (HMO I-SNP), Medica Group Advantage Solution (PPO)
- Medical Services Claim Form (PDF) – applies to Medica Advantage Solution (HMO, PPO, HMO-POS, HMO I-SNP), Medica Group Advantage Solution (PPO)
- Travel Reimbursement Form (PDF) – applies to Medica Advantage Solution (HMO, PPO, HMO-POS, HMO I-SNP), Medica Group Advantage Solution (PPO)
Looking for 2020 Claim Forms?
Determinations, Appeals and Grievances
Enrollment Forms