Forms

Below please find various forms for you to print and complete.

CVS/caremark Reimbursement:  If you have to pay out of pocket for prescriptions prior to being activated with CVS/caremark you can complete a form and file for a reimbursement.

MHS Manual Claim Form:  In some circumstances, you may be required to pay upfront for medical services. For example, if you are traveling outside the country, you may be required to pay for medical services with a credit card or cash. If you should pay upfront for a medical service, a manual claim form can be submitted to Mutual Health Services along with the invoice from the provider of service.

Protected Health Information:  To enable spouse, child, power of attorney, guardian, or other person to receive protected health information from the EHP, Medical Management and/or TPA related to health plan programs or services. Mutual Health Services PHI form, UMR PHI form

MHS Coordination of Benefits:  Mutual Health Services (MHS) has partnered with COB Smart® to more efficiently identify EHP members who have other insurance coverage. MHS receives weekly files from COB Smart® with those EHP members matching other insurance and will automatically update your record. This means less paperwork for most EHP members. Some smaller insurance companies may not currently participate in COB Smart®. In these instances, you will be asked by Mutual Health Services to complete the COB form. Detailed instructions on how to complete the process are on the form.

UMR Coordination of Benefits:  Coordination of Benefits is one of the many administrative functions they provide which helps achieve cost savings for both the health plan and the member.  UMR utilizes their Employee Questionnaire below to complete the COB process. You can also complete the process via their website at UMR.com or by calling 800.826.9781.