This is a selection of important forms available to you as a customer. To view all your forms,
Medical Appeal Request:
Medical Claim Form:
Direct Member Reimbursement (DMR):
Transition of Care / Continuity of Care (with Mental Health) Forms:
For California-specific forms and plan information, visit our
Arizona Specific Forms
Colorado Specific Forms
Florida Specific Forms
Hawaii Specific Forms
Indiana Specific Forms
Massachusetts Specific Forms
Michigan Specific Forms
Nebraska Specific Forms
New Jersey Specific Forms
New Mexico Specific Forms
Texas Specific Forms
Vermont Specific Forms
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.
West Virginia Specific Forms
Dental Claim Form
Transition of Care/Continuity of Care Form
Transition of Care/Continuity of Care Form-AZ Medicare
For California-specific forms and plan information, visit our
New Hampshire Specific Forms
Outline of Coverage Form -
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 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.
Cigna Vision (VSP) Claim Forms:
Cigna Vision (VSP) Claim Forms (fillable version):
Cigna Vision serviced by EyeMed Claim Forms:
Cigna Vision serviced by EyedMed Claim Forms (fillable version):
New Hampshire Specific Forms
Outline of Coverage Form -
Arizona Specific Forms
Florida Specific Forms
Indiana Specific Forms
Maryland Specific Forms
Massachusetts Specific Forms
New Mexico Specific Forms
Vermont Specific Forms
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.
West Virginia Specific Forms
For California-specific forms and plan information, visit our
Care for family member
Military Leave
Bonding Leave
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 at
For forms related to privacy and legal matters, visit the
Looking for plan documents?
You can find Summary Benefits of Coverage and Outlines of Coverage for medical and dental plans, past and present.Visit our Knowledge Center to learn more about:
Member Guide Quick Links
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
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 representative.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna 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