Medical Mutual - Health Plans for Life

Update Your Records

Please complete this form with any changes to your physician/ provider offices. If you have questions, please contact your professional contracting representative. Please allow 30 days for changes to be made. The following record changes may affect your listing in the provider directory, as well as payment direction:

  • New provider(s) added to a group practice
  • Provider(s) leaving the group practice
  • Change in Medicare-approved provider ID number or group number
  • Practice moves to a new location
  • Addition of a new location
  • Change in reimbursement address

For a change in your tax ID number or company/practice name, please contact your local Professional Contracting Representative.

Ancillary Providers Click Here

For Professional Providers

 

Fields marked with * are required.

  • *Request Type:
  • *Provider Type:
  • If deleting a PCP, move members to:

Identification Information

  • *Last Name:
  • *First Name:
  • Initial:
  • *Title: (M.D., etc.)
  • Medical License Number:
  • NPI Number:
  • *Social Security Number:
  • *Specialty:
     
  • Effective Date:
  • PHO Affiliation:

Practice Affiliation Information

  • *Federal Tax ID Number:
  • *Location Name:
  • Medicare Number:
  • Medicaid Number:
  • List Location in Directory?:

  • Mailing Address?:

  • *Street Address:
  • *City:
  • State:
  • County:
  • *Zip + 4:
    -
  • Accepting New Patients?:

  • Office Phone:
  • Fax:
  • *Office Days and Hours:

Additional Practice Locations for Above Practice Affiliations

  • Practice Location Name:
  • List Location in Directory?:

  • Mailing Address?:

  • Street Address:
  • City:
  • State:
  • County:
  • Zip + 4:
    -
  • Office Phone:
  • Fax:
  • Office Days and Hours:

Reimbursement Address Information

  • *Reimbursement Name:
  • *Federal Tax ID No. of Reimbursement Entity:
  • I certify under penalty or perjury that the Tax
          Identification Number I have provided is correct.
  • Type of Entity:




  • *Street Address / P.O. Box:
  • *City:
  • State:
  • *County:
  • *Zip + 4:
    -
  • Phone:
  • Fax:
  • Office Manager or Assistant:
  • *Name of Individual Completing this Form:

Comments

For Ancillary Providers

If you are an ancillary provider, please submit your update (e.g. address changes, tax identification, number changes, etc.), to Ancillary Contracting in writing. Contact Us as follows:

Ancillary Contracting Updates

Phone 216-687-7466

Fax 216-687-1450

Regular Mail:
2060 East 9th Street
Mail Zone 01-5B-3860
Cleveland, OH 44115-1355

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