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.

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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*:

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