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    Customer Forms

    Medical Forms

        California Specific Forms

    Medical Claim Appeal Requests

    Transition of Care / Continuity of Care with Mental Health
    Continuidad de la atención médica
    forms_continuity_of_careTC4
    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

    Dental Forms

        California Specific Forms

    Dental Claim
    Cigna Dental Oral Health Integration Program Reimbursement Form

    Pharmacy Forms

    Ampyra
    Angiotensin Receptor Blockers (ARB)
    Antifungal coverage form
    Cigna Home Delivery Pharmacy Prescription Order Form
    Compounds
    DACON Coverage
    Erectile Dysfunction Coverage
    Hepatitis C antivirals
    Insulin Pens
    Mandatory Mail Order Exception Form
    Narcotic Medications
    Pharmacy Claim Form (Not for Medicare Customers — see Medicare Pharmacy Claim Form)
    Medication Prior Authorization
    Medicare-B Assignment of Benefits
    Medicare Pharmacy Claim Form
    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
    HIV Medications
    Humira
    Infertility
    Joint Degenerations
    Kineret
    Lupron®
    Multiple Sclerosis
    Oncology
    Orencia
    Remicade®
    Rituxan
    Simponi
    Specialty Injectable Drug
    Synagis®
    Vectibix
    Xolair®

    Vision Forms

    Cigna Vision claim
    Indemnity Vision (medical) claim

    Behavioral Forms

        California Specific Forms

    Behavioral Health Customer Claim Form

    Disability/Accident/Life/Critical Illness Forms

    Short-term Disability
    Long-term Disability

    Disability Disclosure Authorization

    Life and Accidental Death
    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
    Accidental Dismemberment, Injury or Disability
    Critical Illness

    Cigna Choice Fund HRA/FSA Claim Forms

    Debit Card Validation
    FSA Dependent Care Reimbursement
    FSA Reimbursement
    HRA Reimbursement

    Re-Employment Solutions

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

    California Specific Forms

    CA Grievance Brochure
    Folleto sobre quejas formales en CA

    CA Medical Grievance Form
    Formulario de queja formal de indole médica para CA
    medical_grievance_formTC6
    CA Dental Grievance Form
    Formulario de queja formal para CA Dental
    dentalmember_grievance_formTC9
    CA Behavioral Health Grievance Form
    Formulario de queja formal para CA
    Ca_GrievanceForm_TC12
    CA Continuity of Care Form
    Formulario de de continuidad de la atención médica para CA
    ca_continuity_of_careTC15
    CA Transition of Care Form
    Formulario de transición de la atención médica para CA
    ca_continuity_of_careTC18
    Language Assistance Disclosure

    Colorado Specific Forms

    CO Customer Appeal Request Form

    International Forms
    Stay-at-Work Services

    Stay at Work Services FAQ and Authorization

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