Reserve National

A Kemper Life & Health Company

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.

	Reserve National Insurance 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 - Credit Card 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 the top portion of this form and submit it with a voided check from the account from which you want us to draft. Another easy way to pay your premium is with your credit card. Complete the bottom portion of this form and submit it.
	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. Their website is www.FirstHealth.com.
	Beech Street - Network Form To research a claim processed with the Beech Street Network, please complete this form and submit it per the instructions on the form.
	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, please complete this form and Mail it to: Reserve National Insurance Company 601 E Britton Rd Oklahoma City, OK 73114 Arkansas, Colorado, Kentucky, Oklahoma, Texas, and New Mexico have a second page. If you are resident in these states, please download the second page by clicking on your state of residence name.