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 ClaimCigna Dental Oral Health Integration Program Reimbursement Form
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
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