Member Forms

Use our forms to help manage your health plan and flexible spending account (FSA). If you have any questions, contact Customer Service using the number on your ID card.

Claim Forms

Medical 
Mail this form to the address listed on the back of your member identification (ID) card.

Dental
Mail this form to: Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018

Vision
Mail this form to: Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018

Prescription Drug Claim form for Major Medical Benefits 
Please Note: Use this form only if you forget your card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.

Prescription Drug Claim form for Drug Card Benefits 
Please Note: Use this form only if you forget your card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.

FlexSave Health Care and Dependent Care 
Please Note: Your plan must be administered by Medical Mutual Services to use this form. Contact Customer Service at 800.525.9252 with questions.

FlexSave Parking and Transportation 
Please Note: Your plan must be administered by Medical Mutual Services to use this form. Contact Customer Service at 800.525.9252 with questions.

Miscellaneous Forms

Adult Dependent Form
Mail this form to: Medical Mutual, P.O. Box 943, Toledo, OH 43656-0001

Disability Verification
Mail this form to: Medical Mutual, 2060 East 9th Street, Cleveland, OH 44115-1355

FlexSave Direct Deposit Form 
Please Note: Your plan must be administered by Medical Mutual Services to use this form. Contact Customer Service at 800.525.9252 with questions.

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