Amendment Request Form - Mutual of Omaha 2026

1. Click ‘Get Form’ to open the Amendment Request Form in the editor.
2. Begin by filling in your personal information. Enter your name, address, city, state, and zip code in the designated fields.
3. Provide your home telephone number and policy/group number. If applicable, include the subscriber number if your coverage is through an employer.
4. In the section requesting details about the amendment, be specific about the record type, location, date, and nature of the problem. If amending a provider's record, attach a copy of their amended record.
5. Print your name and indicate your relationship to the individual whose records are being amended. Sign and date the form at the bottom.
6. Ensure that you or an authorized representative has signed the form before submission. If you're an authorized representative, provide necessary documentation.
7. Return the completed form along with any attachments to Mutual of Omaha at their specified address.

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