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  • Home Individuals & Families Member Guide Cigna Healthcare Customer Forms

    Cigna Healthcare Customer Forms

    Easy access to a selection of important forms.

    Are you a member?

    Activate your myCigna account for access to all plan details and live, 24/7 support.


    Activate your account nowWhy activate your account?

    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]

    *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]

    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]

    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]

    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]

    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

    ADA American Dental Association Dental Claim Form [PDF]

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

    Dentist Directory Request

    Patient Charge Schedule Request

    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 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.

    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.

    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]

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

    Indemnity Vision (medical) claim [PDF]

    Cigna Vision serviced by EyeMed Claim Forms: English [PDF] | Spanish [PDF]

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

    New Hampshire Specific Forms

    Outline of Coverage Form - Vision

    Behavioral Forms

    Behavioral Appeal Request: Printable [PDF] | Fillable [PDF]

    *For a Medical Appeal Form, please see the Medical Forms section above.

    Behavioral Health Customer Claim Form [PDF]

    Behavioral Transition of Care/Continuity of Care Request Form (fillable) [PDF]

    Behavioral Transition of Care/Continuity of Care Request Form Instructions [PDF]

    Arizona Specific Forms

    Arizona Prior Authorization Form [PDF]

    Florida Specific Forms

    Florida Uniform Prior Authorization Form [PDF]

    Florida Prior Authorization Form - Instructions [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]

    Massachusetts Psychological and Neuropsychological Assessment Supplemental Form (fillable) [PDF]

    Nevada Specific Forms

    Nevada Uniform Prior Authorization Form [PDF]

    New Mexico Specific Forms

    New Mexico Prior Authorization Form [PDF]

    Tennessee Specific Forms

    Tennessee ABA Prior Authorization Form (fillable) [PDF]

    Tennessee IOP Request Form [PDF]

    Tennessee Transcranial Magnetic Stimulation (TMS) Request Form (fillable) [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 Healthcare in California page.

    Uniform Medical Prior Authorization Form [PDF]

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

    Life, AD&D, or Disability Claims

    New York Paid Family Leave Forms

    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?

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

    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.

    I want to...
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  • View my claims and EOBs
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  • Find a form
  • Find 1095-B tax form information
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  • Contact Cigna Healthcare
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    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); (ii) Life Insurance Company of North America (“LINA”) (Philadelphia, PA); or (iii) New York Life Group Insurance Company of NY (“NYLGICNY”) (New York, NY), formerly known as Cigna Life Insurance Company of New York. The Cigna Healthcare name, logo, and other Cigna Healthcare marks are owned by Cigna Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of The Cigna Group.

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