Customer Forms

Medical Forms
  • Change Primary Care Physician
  • Medical 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

    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 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

    Dental Forms

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

    CA Dental Grievance Form | Formulario de queja formal para CA Dental | dentalmember_grievance_formTC9

    Pharmacy Forms

    Cigna Home Delivery Pharmacy Prescription Order Form

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

    Medicare-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

    CA Behavioral Health Grievance Form | Formulario de queja formal para CA | Ca_GrievanceForm_TC12

    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 FSA Reimbursement HRA Reimbursement

    Re-Employment Solutions

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

    International Forms

    Login to Cigna Envoy for Cigna Global Health Benefits forms.

    Stay-at-Work Services

    Stay at Work Services FAQ and Authorization