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Forms

For Medica Advantage Solution Members

Plan Management Forms

• 2021 Automatic payment form (PDF)
• Appoint a representative form (PDF)
• Medicare Part D prescription claim form (PDF)
• Reimbursement instructions for prescription Part D costs (PDF)

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

• Advantage Solution determinations, appeals and grievances

Enrollment Forms

• 2021 Advantage Solution Enrollment Application IA NE (PDF)
• 2021 Advantage Solution Enrollment Application MN (PDF)
• 2021 Advantage Solution Enrollment Application Southeast MN (PDF)