Online Forms

How to Submit Your Claim
A guide for submitting a claim when the service provider does not submit the claim directly.

MedMutual Protect Claim Form
Should be filled out completely and submitted with the physician and/or hospital bill. See the Notice to Residents on page 2 of the claim form.

Home Health Certification Claim Form
Physician's Home Health Care Certification claim form, see the Notice to Residents on page 2 of the claim form.

• Note: If you are resident in Texas, please use this form.

Bank Draft Authorization Form 
If you would like to have your premiums drafted from your bank account, or you currently have this option and you need to change your banking information, complete this form and submit it with a voided check from the account from which you want us to draft.

Glossary of Health Coverage and Medical Terms
This glossary has many commonly used terms. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. In cases where the terms and definitions differ, the policy governs. 

First Health - Network Form
First Health Network provides information related to participation and pricing. If you have a concern regarding your status in their network or the repriced amount on an allowed claim, contact First Health by calling 1-800-.937-.6824. The First Health website also lets you review frequently ask questions, join the network, change demographic information or get a copy of the provider manual. 

To locate a First Health Network Provider, Click Here.

Multiplan - Network Form
To research a claim processed with the MultiPlan Network, please complete this form and submit it per the instructions on the form. 

Health Care Provider Claim Inquiry
To investigate the way MedMutual Protect has processed a particular claim, complete and submit this form.