Forms for Senior Solutions Policyholders

MedMutual Protect Senior Solutions Insurance 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 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 the top portion of this form and submit it with a voided check from the account from which you want us to draft.

You can also choose to pay your premium by credit card. Complete the bottom portion of Bank Draft Authorization Form and submit it.

Health Care Provider Claim Inquiry
To investigate the way MedMutual Protect Senior Solutions Company has processed a particular claim, complete and submit the 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. Please complete form and mail it to:

MedMutual Protect Senior Solutions
P.O. Box 9965
Austin, TX 78766-9965   

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