Form Library
Blue Cross Blue Shield
Delta Dental
| DELTA DENTAL MASTER APPLICATION |
| DELTA DENTAL ENROLLMENT FORM - MN, ND |
| DELTA DENTAL ONE-TIME LOAD CENSUS FORM |
Health Partners
Medica
FIND A PHYSICIAN or FACILITY
ORDER AN ID CARD
MAKE A ONE-TIME PREMIUM PAYMENT
2024 OFFICIAL PLAN DOCUMENTS
FORMS
ORDER AN ID CARD
MAKE A ONE-TIME PREMIUM PAYMENT
2024 OFFICIAL PLAN DOCUMENTS
FORMS
| AUTHORIZTION TO DISCLOSE PROTECTED HEALTH INFORMATION |
| STATEMENT OF CLAIMS |
| PRESCRIPTION DRUG REIMBURSEMENT - EXPRESS SCRIPTS |
| PLAN SELECTION/CHANGE FORM - MN, ND, SD, WI |
| NEW GROUP ENROLLMENT FORM |
| SMALL EMPLOYER GROUP APPLICATION |
| LARGE EMPLOYER GROUP APPLICATION |
| GROUP ENROLLMENT/CHANGE/CANCELLATION FORM |
| MN LARGE/SMALL GROUP SURVEY |
| CONTROLLED GROUP SURVEY |
Medica Group
Medica Insurance Company Group Insurance
| EMPLOYEE APPLICATION FORM (for groups with no previous coverage) |
| EMPLOYER GROUP APPLICATION (1-50) |
| EMPLOYER GROUP APPLICATION (51+) |
| MEDICA PLAN SELECTION AND CHANGE FORM (5-digit group number) |
| GROUP ENROLLMENT/CHANGE/CANCELLATION FORM |
| AUTHORIZATION TO DISCLOSE PROTECTED HEALTHINFORMATION (HIPAA AUTHORIZATION) |
| 2020 PRESCRIPTION CLAIM FORM |
| STATEMENT OF CLAIMS |
| DELTA DENTAL MASTER APPLICATION |
| DELTA DENTAL - ENROLLMENT FORM |
| DELTA DENTAL – “ONE TIME LOAD” CENSUS STYLE ENROLLMENT FORM |
Medica Product Information and Fliers
| ACO PRODUCTS OVERVIEW EMPLOYER BROCHURE |
| ALTRU & YOU MEMBER FLIER |
| ALTRU & YOU EMPLOYER FLIER |
| CLEAR VALUE with MEDICA MEMBER FLIER |
| CLEAR VALUE with MEDICA EMPLOYER FLIER |
| MEDICA EMPLOYER-PROVIDED PRODUCTS |
| ESSENTIA CHOICE CARE with MEDICA EMPLOYER FLIER |
| ESSENTIA CHOICE CARE with MEDICA MEMBER FLIER |
| MEDICA CHOICE PASSPORT EMPLOYER FLIER |
| MEDICA CHOICE PASSPORT MEMBER FLIER |
| MEDICA ELECT EMPLOYER FLIER |
| MEDICA ELECT MEMBER FLIER |
| PARK NICOLLET AND HEALTH PARTNERS MEDICAL FIRST GROUP with MEDICA EMPLOYER FLIER |
| PARK NICOLLET AND HEALTH PARTNERS MEDICAL FIRST GROUP with MEDICA MEMBER FLIER |
| RIDGEVIEW COMMUNITY NETWORK MEMBER FLIER |
| RIDGEVIEW COMMUNITY NETWORK EMPLOYER FLIER |
| TRAVEL PROGRAM EMPLOYER FLIER |
| VANTAGEPLUS with MEDICA EMPLOYER FLIER |
| VANTAGEPLUS with MEDICA MEMBER FLIER |
| MINNESOTA SERVICE AREA MAP |
| WISCONSIN SERVICE AREA MAP |
UCare
