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Cigna Healthcare Customer Forms
Easy access to a selection of important forms.
Log in to your myCigna account
Are you a member?
Activate your myCigna account for access to all plan details and live, 24/7 support.
This is a selection of important forms available to you as a customer. To view all your forms, log in to myCigna.
Medical Forms
Request a Medical ID card on myCigna
Change Primary Care Physician
Medical Appeal Request: English [PDF] | Spanish [PDF] | Chinese [PDF]
*For a Behavioral Health Appeal Form, please see the Behavioral Forms section below.
Medical Claim Form: English [PDF] | Spanish [PDF]
Direct Member Reimbursement (DMR): English [PDF]
Appointment of Representative Form: English [PDF]
Appointment of Representative Form (fillable version): English [PDF]
Transition of Care / Continuity of Care (with Mental Health) Forms: English [PDF] | Spanish [PDF] | Chinese [PDF]
Transition of Care / Individual and Family Plans [PDF]
For California-specific forms and plan information, visit our Cigna Healthcare in California page.
Arizona Specific Forms
AZ Appeals Information Packet [PDF]
Arizona Prior Authorization Form [PDF]
Florida Specific Forms
Florida Prior Authorization Form [PDF]
Hawaii Specific Forms
Disclosure For Conflicts of Interest Evaluation Form [PDF]
HI Request for External Review Form [PDF]
HIPAA Authorization for Release of Information Form [PDF]
Illinois Specific Forms
Illinois HMO Customer Grievance Form [PDF]
Indiana Specific Forms
Indiana Prior Authorization Form [PDF]
Massachusetts Specific Forms
MA Cardiac Imaging Prior Authorization Form [PDF]
MA CT/CTA/MRI/MRA Prior Authorization Form [PDF]
MA PET - PET CT Prior Authorization Form [PDF]
MA Chemotherapy and Supportive Care Prior Authorization Form [PDF]
Michigan Specific Forms
Michigan Nonopioid Directive Form [PDF]
Nebraska Specific Forms
NE External Appeals Request Form [PDF]
New Jersey Specific Forms
New Jersey OON Provider Negotiation [PDF]
New Mexico Specific Forms
New Mexico Prior Authorization Form [PDF]
New Mexico Summary of Grievance Procedures [PDF]
Texas Specific Forms
Texas Standard Prior Authorization Request Form for Health Care Services [PDF]
Vermont Specific Forms
Uniform Medical Prior Authorization [PDF]
Virginia Specific Forms
These forms may only be used if your employer is head quartered in the Commonwealth of Virginia, and you are enrolled in a medical, behavioral, pharmacy or dental plan that is underwritten by Cigna Health and Life Insurance Company. If you have any questions please contact us at the phone number listed on the back of your identification card.
Virginia Specific Appointment of Authorized Representative [PDF]
External Review Request Form [PDF]
Physician Certification Expedited External Review Request Form [PDF]
Physician Certification Experimental or Investigational Denials Form [PDF]
West Virginia Specific Forms
Dental Forms
ADA American Dental Association Dental Claim Form [PDF]
Dental Claim Form English [PDF] | Spanish [PDF]
Transition of Care/Continuity of Care Form English [PDF] | Spanish [PDF] | Chinese [PDF]
Transition of Care/Continuity of Care Form-AZ Medicare English [PDF] | Spanish [PDF]
For California-specific forms and plan information, visit our Cigna Healthcare in California page.
New Hampshire Specific Forms
Outline of Coverage Form - Dental
Virginia Specific Forms
These forms may only be used if your employer is head quartered in the Commonwealth of Virginia, and you are enrolled in a medical, behavioral, pharmacy or dental plan that is underwritten by Cigna Health and Life Insurance Company. If you have any questions please contact us at the phone number listed on the back of your identification card.
Virginia Specific Appointment of Authorized Representative [PDF]
External Review Request Form [PDF]
Physician Certification Expedited External Review Request Form [PDF]
Physician Certification Experimental or Investigational Denials Form [PDF]
Pharmacy Forms
Home Delivery Pharmacy Prescription Order Form [PDF]
Pharmacy Claim Form [PDF] (Not for Medicare Customers — see Medicare Pharmacy Claim Form)
Pharmacy Claims - Helpful Hints [PDF]
Medicare-B Assignment of Benefits [PDF]
Medication Prior Authorization Form [PDF]
Virginia Specific Forms
These forms may only be used if your employer is head quartered in the Commonwealth of Virginia, and you are enrolled in a medical, behavioral, pharmacy or dental plan that is underwritten by Cigna Health and Life Insurance Company. If you have any questions please contact us at the phone number listed on the back of your identification card.
Virginia Specific Appointment of Authorized Representative [PDF]
External Review Request Form [PDF]
Physician Certification Expedited External Review Request Form [PDF]
Physician Certification Experimental or Investigational Denials Form [PDF]
Vision Forms
Cigna Vision (VSP) Claim Forms: English [PDF] | Spanish [PDF]
Indemnity Vision (medical) claim [PDF]
Cigna Vision serviced by EyeMed Out of Network Claim Forms: English [PDF] | Spanish [PDF]
Cigna Vision serviced by EyedMed Exception Claim Forms: English [PDF] | Spanish [PDF]
New Hampshire Specific Forms
Outline of Coverage Form - Vision
Behavioral Forms
Behavioral Appeal Request (printable version): English [PDF] | Spanish [PDF] | Chinese [PDF]
Behavioral Appeal Request (filllable version): English [PDF] | Spanish [PDF] | Chinese [PDF]
*For a Medical Appeal Form, please see the Medical Forms section above.
Behavioral Health Customer Claim Form [PDF]
Behavioral Appointment of Representative Form: English [PDF]
Behavioral Appointment of Representative Form (fillable version): English [PDF]
Behavioral Transition of Care/Continuity of Care Request Form (fillable) [PDF]
Behavioral Transition of Care/Continuity of Care Request Form Instructions [PDF]
Virginia Specific Forms
These forms may only be used if your employer is head quartered in the Commonwealth of Virginia, and you are enrolled in a medical, behavioral, pharmacy or dental plan that is underwritten by Cigna Health and Life Insurance Company. If you have any questions please contact us at the phone number listed on the back of your identification card.
Virginia Specific Appointment of Authorized Representative [PDF]
External Review Request Form [PDF]
Physician Certification Expedited External Review Request Form [PDF]
Physician Certification Experimental or Investigational Denials Form [PDF]
For California-specific forms and plan information, visit our Cigna Healthcare in California page.
Accidental Injury, Critical Illness, Hospital Care, and Wellness Incentive Claim Forms
Life, AD&D, or Disability Claims
New York Paid Family Leave Forms
Care for family member
Claim Form for Benefits PFL 1[PDF]
Military Leave
Claim Form for Benefits PFL 1 [PDF]
Family Medical Leave Forms
Cigna Choice Fund HRA/FSA Claim Forms
Important Health Coverage Tax Documents
Form 1095-B provides important tax information about your health coverage.
To request your 1095-B form, you can:
- Log in to your myCigna account and download a copy from the Forms Center
- Mail a request for statement to:
900 Cottage Grove Road
Bloomfield, CT 06152 - Be sure to include your full name, account number, and customer ID or Social Security Number (SSN)
If you have questions about your 1095-B form contact Cigna HealthcareSM at
Privacy Forms
For forms related to privacy and legal matters, visit the Privacy Forms page.
Looking for plan documents?
Visit our Knowledge Center to learn more about:
Member Guide Quick Links
The Dental Oral Health Integration Program
This program provides reimbursement for certain eligible dental procedures for customers with qualifying medical conditions. Customers must enroll in the program prior to receiving dental services to be eligible for reimbursement. Reimbursement is applied to and subject to any applicable annual benefits maximum. See your plan documents or contact Cigna Healthcare for complete program details.
The State of Colorado Notice-Access Plan
You may request a copy of our Access Plan. The Access Plan is designed to disclose all the policy information required under Colorado law. It is available for your review upon request and explains 1) Who participates in our provider network; (2) how we ensure that the network meets the health care needs of our members; (3) how our provider referral process works: (4) how care is continued if providers leave our network; (5) what steps we take to ensure medical quality and customer satisfaction; (6) where you can go for information on other policy services and features.
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Audiences
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Cigna Healthcare Information
The Cigna Group Information
Disclaimer
Product availability may vary by location and plan type and is subject to change. All health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna Healthcare representative.
All Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc. and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of The Cigna Group Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT). The Cigna Healthcare name, logo, and other Cigna Healthcare marks are owned by Cigna Intellectual Property, Inc. This website is not intended for residents of New Mexico.
La aseguradora publica el formulario traducido para fines informativos y la versión en inglés prevalece para fines de solicitud e interpretación.
The insurer is issuing the translated form on an informational basis and the English version is controlling for the purposes of application and interpretation.