Health Care Professional Forms

Medical Forms

• Explanation of Direct Deposit Activity Report[82k]
• UB-04 [15k]
• CMS-1500 (HCFA1500)[179k]
• Request for Provider Payment Appeal (NJ) - Instructions & Form[60k]
• Request for Provider Payment Appeal (all others) - Instructions & Form[160k]
• Provider Dispute Resolution Request (California HMO) - Instructions & Form[160k]
• Direct Deposit Authorization Form[160k]
• Case Management Referral Form[58k]

Dental Forms

Add a Dentist (online form)
Dental Claim[1.4Mb]
DHMO Uniform Referral for Maryland[42k]

Pharmacy Forms

• Ampyra [31k]
• Angiotensin Receptor Blockers(ARB)[29k]
• Antifungal Coverage form[53k]
• Compounds[32k]
• DACON Coverage[153k]
• Erectile Dysfunction Coverage[38k]
• Insulin Pens[29k]
• Mandatory Mail Order Exception Form[28k]
• Narcotic Medications[34k]
• Pharmacy Claim Form[63k]
• Medication Prior Authorization[154k]
• Medicare Pharmacy Claim Form[197k]
• Tel-Drug Profile[154k]
• Selzentry[29k]
• Singulair[29k]
• Tamiflu/Relenza[32k]
• Tykerb[28k]
• Weight Management Medications[28k]

Chemotherapy Medications

• Halaven[36k]
• Jevtana[32k]
• Treanda[104k]

Additional Forms available on cignaforhcp.com (log in required)