Please enter your information below. Attach the enrollment document(s) you would like to securely submit to Medica's enrollment department. Upon submission you will receive an e-mail confirming receipt. Only Medica’s Group Enrollment/Change/Cancellation Form and Medica Approved Enrollment Spreadsheets are accepted.

Note: Please retain the original document(s) and the receipt page for your records. You do not need to mail or fax these documents to us.