Cultural Comp etence of Network Form

Medical Mutual recognizes that some covered persons have special needs or preferences that may affect the administration of their health plan or their ability to obtain medical services. If you are a provider who can address the special needs or preferences of the Company covered persons who speak a language other than English, who are visually impaired, or who have specific social/cultural needs, then we need your help. Please notify the Company of the other language(s) you speak, the special service you provide, or the need or preference you are able to address by completing and submitting the form below. The information you provide will be kept in a database and referenced when a covered person calls us with special needs.

Please Note: In order for us to provide you with this service, you will need to supply the requested information.

See our privacy statement for more information about our policies.

Fields marked with an asterisk (*) are required.

Cultural Competence of Network and Health Plan Information Form

• * Last Name:
   
• * First Name:
   
•    Intial:
  
• * Email:
     
• * Social Security Number:
     
• * Address:
   
• * City:
   
• * States:
  Select a state AL-Alabama AK-Alaska AZ-Arizona AR-Arkansas CA-California CO-Colorado CT-Connecticut DE-Delaware FL-Florida GA-Georgia HI-Hawaii ID-Idaho IL-Illinois IN-Indiana IA-Iowa KS-Kansas KY-Kentucky LA-Louisiana ME-Maine MD-Maryland MA-Massachusetts MI-Michigan MN-Minnesota MS-Mississippi MO-Missouri MT-Montana NE-Nebraska NV-Nevada NH-New Hampshire NJ-New Jersey NM-New Mexico NY-New York NC-North Carolina ND-North Dakota OH-Ohio OK-Oklahoma OR-Oregon PA-Pennsylvania PR-Puerto Rico RI-Rhode Island SC-South Carolina SD-South Dakota TN-Tennessee TX-Texas UT-Utah VT-Vermont VA-Virginia WA-Washington WV-West Virginia WI-Wisconsin WY-Wyoming
• * Zip:
     
• * Contact Phone:
     
•    Fax:
  
• * How do you want us to contact You?:
  E-mailPhoneLetter  
•    Non-English Languages spoken fluently:
  
•    Other cultural, ethnic, or social issues you are comfortable addressing with patients:
  
•    Feedback on other issues that exist base on personal experience (that you are not able to address):
  

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