Customer Forms

Medical Forms

Request a Medical ID card
Change Primary Care Physician
Medical Appeal Requests
Medical Claim Form

Transition of Care / Continuity of Care (with Mental Health) Forms:  English | Spanish | Chinese
Transition of Care / Continuity of Care (without Mental Health) Forms: English | Spanish | Chinese

Update your Health Plan coverage-Spouse
Update your Health Plan coverage-Child
Update your Health Plan coverage-Medicare
Update your Health Plan coverage-Duplicate

For California-specific forms and plan information, visit our Cigna in California page.

Colorado Specific Forms

CO Customer Appeal Request Form

Nebraska Specific Forms

NE External Appeals Request Form

Dental Forms

Dental ClaimCigna Dental Oral Health Integration Program Registration FormCigna Dental Oral Health Integration Program Registration Form (Spanish)

For California-specific forms and plan information, visit our Cigna in California page.

Pharmacy Forms

Cigna Home Delivery Pharmacy Prescription Order Form

Pharmacy Claim Form(Not for Medicare Customers — see Medicare Pharmacy Claim Form)

Pharmacy Claims - Helpful HintsMedicare-B Assignment of BenefitsMedicare Pharmacy Claim Form

 

You or your health care professional can submit an online prior authorization request for prescription drugs covered under the Cigna pharmacy benefit or the Cigna medical benefit at: https://cigna.promptpa.com.

This easy tool will walk you through submitting an online prior authorization request for your medication. Once your request is submitted, Cigna will contact your health care professional to complete the process.

Vision Forms

Cigna Vision claim Indemnity Vision (medical) claim

Behavioral Forms

Behavioral Health Customer Claim Form

For California-specific forms and plan information, visit our Cigna in California page.

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

Canadian Cigna Identify Theft Flyer

Canadian Cigna Identity Theft Flyer (French)

Canadian Cigna Secure Travel Flyer

Canadian Cigna Secure Travel Flyer (French)

Canadian Long Term Disability Intake Form

Canadian Long Term Disability Intake Form (French)

Cigna Choice Fund HRA/FSA Claim Forms

Debit Card Validation FSA Dependent Care Reimbursement Dependent Care FSA Reimbursement Helpful Hints FSA Reimbursement HRA Reimbursement FSA and HRA Reimbursement Helpful Hints

International Forms

Login to Cigna Envoy for Cigna Global Health Benefits forms.

Healthy Working Life Forms

Authorization

Healthy Working Life FAQ and Referral Form