Medical Mutual - Health Plans for Life

Provider Information Form

Professional Providers: Please complete the web form on this page to update your records and click Submit.

Any fields with incomplete information could delay or cause your request to be returned unprocessed.

Ancillary and institutional providers: Please complete the PDF version of the provider information form to update your records and fax it to your regional Provider Contracting office.

Ancillary and institutional providers, except ambulance and diagnostic laboratory providers: When adding a new office or a facility location, you must also submit the required credentialing application. For all other ancillary inquiries: please call (877) 271-4093.

To update your records by U.S. mail: Please complete and print the PDF version of the provider information form and credentialing application (if applicable), and mail or submit them per the forms' instructions.

acrobatTo view the PDF files, or if you encounter an error opening the PDF files on this site, download and install the latest free version of Acrobat Reader.

Fields marked with * are required.

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

Identification Information

  • Last Name:*
  • First Name:*
  • Initial:
  • Title (M.D., etc.):*
  • Date of Birth:*
  • Credentialing Needed:
  • CAQH Number:
  • Medical License Number:
  • NPI Number:*
  • Social Security Number:
  • Specialty:*
  • Effective Date of Action:

Practice Affiliation Information

  • Federal Tax ID Number:* 
  • Location Name:*
  • Street Address:*
  • City:*
  • State:
  • County:
  • Zip + 4:* -
  • Accepting New Patients?:
  • Office Phone:
  • Fax:

Additional Locations for Above Practice Affiliations

  • Location Name:
  • Street Address:
  • City:
  • State:
  • County:
  • Zip + 4: -
  • Office Phone:
  • Fax:

Reimbursement Address Information

  • Reimbursement Name:*
  • Federal Tax ID No. of
    Reimbursement Entity:*
  • ID Accurate*:
  • Type of Entity:




  • Street Address / P.O. Box:*
  • City:*
  • State:
  • County:*
  • Zip + 4:* -
  • Name of Individual
    Completing this Form*:

This Medical Mutual website may contain links to other Internet sites (“Third Party Sites”) that are not maintained by or under the control of Medical Mutual. These links are provided solely for your convenience, and you access them at your own risk. Medical Mutual makes no warranties or representations about the contents of products, services or information offered in such Third Party Sites. Consequently, Medical Mutual is not and cannot be held responsible for the accuracy, copyright compliance, legality or decency of material contained in Third Party Sites linked to this Medical Mutual website.

© 2017 Medical Mutual®