Reserve National Insurance Company Reserve National: A Kemper Life and Health Company. Call Us Toll Free at 800.654.9106
Home  >  Resources  >  Online Forms
HIPAA Transactions
For more information on electronic HIPAA Transactions, see the Providers Information.
Online Forms
Click on the name of the form you need in order to download the form or print out a copy directly from your PC.
How to Submit Your Claim 
A guide for submitting a claim when the service provider does not submit the claim directly.
 
MedMutual Protect Claim Form 
Should be filled out completely and submitted with the physician and/or hospital bill. See the Notice to Residents on page 2 of the claim form.

 
Bank Draft Authorization Form 
If you would like to have your premiums drafted from your bank account or you currently have this option and you need to change your banking information, complete this form and submit it with a voided check from the account from which you want us to draft.

 
Glossary of Health Coverage and Medical Terms 
This glossary has many commonly used terms, but isn't a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs.

 
First Health - Network Form 
First Health Network provides us all our information in regards to participation and pricing. If you have a concern regarding your status in their network or the repriced amount on an allowed claim, we recommend that you contact them directly for assistance. First Health customer service will be able to research and address your concerns and can be reached at 800.937.6824. They also have a very extensive website that allows you to review frequently ask questions, join the network, change demographic information or get a copy of the provider manual.

To locate a First Health Network Provider Click Here

 
Multiplan - Network Form 
To research a claim processed with the MultiPlan Network, please complete this form and submit it per the instructions on the form.

 
Health Care Provider Claim Inquiry 
To investigate the way Reserve National Insurance Company has processed a particular claim, please complete this form and submit it per the instructions on the form.

 
Home Health Certification Claim Form
Physician's Home Health Care Certification claim form, see the Notice to Residents on page 2 of the claim form. Please complete this form and Mail it to:

      MedMutual Protect 

      601 E Britton Rd

      Oklahoma City, OK 73114  


If you are resident in Texas, please download the state specific form by clicking on your state name.