Forms
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Insurance Forms for Claims of Service as of November 1, 2009
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Medical Mutual of Ohio Medical Claim Form-Claims must be submitted to Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018.
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Medical Mutual of Ohio Dental Claim Form-Claims must be submitted to Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018.
Flexible Spending Forms for Claims of Service as of January 1, 2010
- CoreFlex/CoreSource Flex Spending Claim Form-Return to Address on Form
- Annualized Dependent Care Reimbursement Form
Flexible Spending Forms for Claims of Service through December 31, 2009
- Flexible Spending Reimbursement Form- For claims of service through 12/31/2009. Send to Address on form.
Additional Insurance Forms
- Sun Life Beneficiary Designation Form - Can be completed with a family status change or at any time. Return to the Personnel Department
- Authorization for Release of Protected Health Information - Return to Personnel Department with any supporting documentation, if any.
General Forms
