Member Forms

	Medical Forms

	Request a Medical ID card (online form)
	Change Primary Care Physician (online form)
	Medical Claim Form
	Continuity of Care (PDF 690k)
	Update your Health Plan coverage - Spouse (PDF 90k)
	Update your Health Plan coverage - Child (PDF 74k)
	Update your Health Plan coverage - Medicare (PDF 122k)
	Update your Health Plan coverage - Duplicate (PDF 91k)
	CIGNA Choice Fund HRA/FSA Claim Forms
	HRA Reimbursement (PDF 690k)
	FSA Dependent Care Reimbursement (PDF 690k)
	FSA Healthcare Reimbursement (PDF 690k)
	FSA Pharmacy Reimbursement (PDF 690k)
	Healthy Future Reimbursement (PDF 690k)
	Healthy Awards Reimbursement (PDF 690k)
	California-specific Forms
	CA Online Grievance Form (online form)
	CA Medical Grievance Form (PDF)
	CA Dental Grievance Form (PDF)
	CA Behavioral Health Grievance Form (PDF)
	CA Continuity of Care Form (PDF)
	CA Transition of Care Form (PDF)

	Dental Forms
	Dentist Directory Request (online form)
	Patient Charge Schedule Request (online form)
	Dental Claim (PDF 1.4M)

	Vision Forms
	VisionCare Claim (PDF 53k)
	Vision Member Claim (PDF 58k)

	Pharmacy Forms
	Prescription Drug (PDF 63k)
	Medication Prior Authorization (PDF 154k)
	Tel-Drug Profile (PDF 154k)
	Specialty (Injectable) Drugs:

	Disability/Accident/Life Forms

	Short-term Disability (PDF)
	Long-term Disability (PDF)
	Submit a Disability Claim (online form)
	Disability Disclosure Authorization
	Submit a Life and Accident Claim (online form)
	Life and Accident Disclosure Authorization
	Physicians Statement of Disability
	Disability Disclosure (PDF)
	Life & Accident (PDF)
	Accidental Death (PDF)
	Dismemberment (PDF)
	Accelerated Death benefits (PDF)
	Disclosure Auth for Deceased Insured Claim (PDF 9k)
	Disclosure Auth for Living Insured Claim (PDF 9k)
	State Income Tax Withholding (PDF)
	Request for Federal Income Tax Withholding (PDF)

	International Forms
	CIGNA International Expatriate Benefits Member Form Center

	Behavioral Care Forms
	Behavioral Health Member Claim Form (PDF)

	Privacy Forms
	Request to Access Health Care Information (PDF)
	Request to Amend Private Health Information (PDF)
	Request for Accounting (PDF)
	Request for Restriction of Use (PDF)
	Request for Confidential Communications (PDF)
	Request for Personal Representative (PDF)
	Statement of Disagreement - Amendment Request (PDF)
	Change/Revoke Request (PDF)
	Authorization for Disclosure of Private Health Information (PDF)