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Home Individuals & Families Member GuideHealth Insurance & Medical Forms for Customers
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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
Change Primary Care Physician

Medical Appeal Request: English [PDF] | Spanish [PDF] | Chinese [PDF]
Medical Claim Form English | Spanish [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 in California page.

Arizona Specific Forms

AZ Appeals Information Packet [PDF]

Arizona Prior Authorization Form [PDF]

Colorado Specific Forms

CO Customer Appeal Request 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]

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]

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]

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.

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

West Virginia Prior Authorization Form [PDF]

Dental Forms

Dental Claim Form English [PDF] | Spanish [PDF]

Dentist Directory Request

Patient Charge Schedule Request

Cigna Dental Oral Health Integration Program® Registration Form (for customers with certain medical conditions) [PDF]

Formulario de inscripción en el programa Oral Health Integration Program® de Cigna Dental (para personas con determinadas afecciones médicas) [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 in California page.

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.

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

Cigna 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]

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.

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 Claim Forms: English [PDF] | Spanish [PDF]

Cigna Vision Claim Forms (fillable version): English [PDF] | Spanish [PDF]

Indemnity Vision (medical) claim [PDF]

Behavioral Forms

Behavioral Health Customer Claim Form [PDF]

Arizona Specific Forms

Arizona Prior Authorization Form [PDF]

Florida Specific Forms

Florida Uniform Prior Authorization Form [PDF]

Florida Prior Authorization Form - Instructions [PDF]

Indiana Specific Forms

Indiana Prior Authorization Form [PDF]

Maryland Specific Forms

Maryland Uniform Treatment Plan Form [PDF]

Massachusetts Specific Forms

Massachusetts Prior Authorization Form [PDF]

Massachusetts Prior Authorization Form – Transcranial Magnetic Stimulation [PDF]

New Mexico Specific Forms

New Mexico Prior Authorization Form [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.

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

West Virginia Prior Authorization Form [PDF]

For California-specific forms and plan information, visit our Cigna in California page. (Cigna in California | Cigna Companies, Products and Disclosures)

Uniform Medical Prior Authorization Form [PDF]

Accidental Injury, Critical Illness, Hospital Care, and Wellness Incentive Claim Forms

Accidental Injury claim form [PDF]

Critical Illness claim form [PDF]

Hospital Care claim form [PDF]

Wellness Incentive claim form [PDF]

Life, AD&D, or Disability Claims

Please submit your claim through New York Life.

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]

Certification of Military Leave PFL 5 [PDF]

Intermittent Absence Time Tracking Form [PDF]

Family Medical Leave Forms

Certification of Health Care Provider for Employee's Own Illness [PDF]

Certification of Health Care Provider for Care of a Family Member [PDF]

Bonding Leave

Birth [PDF]

Adoption [PDF]

Foster [PDF]

Cigna Choice Fund HRA/FSA Claim Forms

Debit Card Validation [PDF]

FSA Dependent Care Reimbursement [PDF]

Dependent Care FSA Reimbursement Helpful Hints [PDF]

FSA Reimbursement [PDF]

HRA Reimbursement [PDF]

FSA and HRA Reimbursement Helpful Hints [PDF]

Healthy Working Life Forms

Authorization [PDF]

Healthy Working Life FAQ and Referral Form [PDF]

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
  • Email us at: 1095BAdvocates@Cigna.com
  • Mail a request for statement to:

    900 Cottage Grove Road
    Bloomfield, CT 06152

If you have questions about your 1095-B form contact Cigna at

Privacy Forms

For forms related to privacy and legal matters, visit the Privacy Forms page.

Looking for plan documents?

You can find Summary Benefits of Coverage and Outlines of Coverage for medical and dental plans, past and present.
View plan documents

Visit our Knowledge Center to learn more about:

What is Prior Authorization and How Does the Process Work?

Copays, Deductibles, and Coinsurance

HSAs, FSAs, and HRAs

View all articles


Member Guide Quick Links

Home Delivery Pharmacy Employee Assistance Program Plan Documents Back to Member Guide

The Cigna 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 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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Disclaimer

Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., and Cigna HealthCare of North Carolina, 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). Group Universal Life (GUL) insurance plans are insured by CGLIC. Life (other than GUL), accident, critical illness, hospital indemnity, and disability plans are insured or administered by Life Insurance Company of North America, except in NY, where insured plans are offered by Cigna Life Insurance Company of New York (New York, NY). All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. This website is not intended for residents of New Mexico.

 Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna website. Cigna may not control the content or links of non-Cigna websites. Details