Customer Forms

Medical Forms

• Request a Medical ID card
• Change Primary Care Physician

Medical Claim Appeal Requests

• Medical Claim Form

Transition of Care / Continuity of Care with Mental Health
Continuidad de la atención médica

Transition of Care / Continuity of Care without Mental Health
Update your Health Plan coverage-Spouse
Update your Health Plan coverage-Child
Update your Health Plan coverage-Medicare
Update your Health Plan coverage-Duplicate

Cigna Choice Fund HRA/FSA Claim Forms

Debit Card Validation
FSA Dependent Care Reimbursement
FSA Reimbursement
HRA Reimbursement

California-specific Forms

• California-specific Plan Information
• CA Online Grievance Form

CA Grievance Brochure
Folleto sobre quejas formales en CA

CA Medical Grievance Form
Formulario de queja formal de indole médica para CA

CA Dental Grievance Form
Formulario de queja formal para CA Dental

CA Behavioral Health Grievance Form
Formulario de queja formal para CA

CA Continuity of Care Form
Formulario de de continuidad de la atención médica para CA

CA Transition of Care FormF
Formulario de transición de la atención médica para CA

Language Assistance Disclosure

Dental Forms

• Dentist Directory Request
• Patient Charge Schedule Request

Dental Claim

Vision Forms

Cigna Vision claim
Indemnity Vision (medical) claim

Pharmacy Forms

Ampyra
Angiotensin Receptor Blockers (ARB)
Antifungal coverage form
Compounds
DACON Coverage
Erectile Dysfunction Coverage
Hepatitis C antivirals
Insulin Pens
Mandatory Mail Order Exception Form
Narcotic Medications
Pharmacy Claim Form
Medication Prior Authorization
Medicare Pharmacy Claim Form
Tel-Drug Profile
Selzentry
Tamiflu/Relenza
Tykerb
Weight Management Medications

Specialty (Injectable) Drugs

Anticoagulant
Avastin
Blood Modifier
Botulinum toxin
Chronic Plaque Psoriasis
Enbrel
Erbitux
Febrile Neutropenia
Fuzeon^®
Growth Hormones
Hemophilia injectible
Hepatitis C antivirals
Herceptin
High Risk Maternity
Hizentra
Humira
Infertility
Joint Degenerations
Kineret
Lupron^®
Multiple Sclerosis
Oncology
Orencia
Remicade^®
Rituxan
Simponi
Specialty Injectable Drug
Synagis^®
Vectibix
Xolair^®

Disability/Accident/Life Forms

Short-term Disability
Long-term Disability

• Submit a Disability Claim

Disability Disclosure Authorization

• Submit a Life and Accident Claim

Life and Accident Disclosure Authorization

• Physician’s Statement of Disability

Total and Permanent Disability / Waiver of Premium
Dismemberment
Accelerated Death Benefits
Disclosure Auth for Deceased Insured Claim
Disclosure Auth for Living Insured Claim
State Income Tax Withholding
Request for Federal Income Tax Withholding
Electronic Fund Transfer Authorization
Verbal Authorization Information

Re-Employment Solutions

Cigna Re-Employment Solutions-Employee
Cigna's Re-Employment Solutions-Brokers

International Forms

• Cigna International Expatriate Benefits Customer Form Center

Behavioral Care Forms

Behavioral Health Customer Claim Form

Privacy Forms