Health Care Claim Forms

Request a Medical ID card
Change Primary Care Physician
English

Medical Appeal Request:  English | Spanish | Chinese
Medical Claim Form English | Spanish

Transition of Care / Continuity of Care (with Mental Health) Forms:  English | Spanish | Chinese

Transition of Care / Individual and Family Plans

For California-specific forms and plan information, visit our Cigna in California page.

Arizona Specific Forms

AZ Appeals Information Packet

Arizona Prior Authorization Form

Colorado Specific Forms

CO Customer Appeal Request Form

Florida Specific Forms

Florida Prior Authorization Form

Hawaii Specific Forms

Disclosure For Conflicts of Interest Evaluation Form

HI Request for External Review Form

HIPAA Authorization for Release of Information Form

Indiana Specific Forms

Indiana Prior Authorization Form

Massachusetts Specific Forms

MA Cardiac Imaging Prior Authorization Form

MA CT/CTA/MRI/MRA Prior Authorization Form

MA PET - PET CT Prior Authorization Form

Nebraska Specific Forms

NE External Appeals Request Form

New Jersey Specific Forms

New Jersey OON Provider Negotiation

New Mexico Specific Forms

New Mexico Prior Authorization Form

Texas Specific Forms

Texas Standard Prior Authorization Request Form for Health Care Services

Vermont Specific Forms

Uniform Medical Prior Authorization

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

External Review Request Form

Physician Certification Expedited External Review Request Form

Physician Certification Experimental or Investigational Denials Form

West Virginia Specific Forms

West Virginia Prior Authorization Form

Dental Claim Form English | Spanish

Dentist Directory Request

Patient Charge Schedule Request

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

Formulario de inscripción en el programa Oral Health Integration Program^® de Cigna Dental (para personas con determinadas afecciones médicas)

Transition of Care/Continuity of Care Form English | Spanish | Chinese
Transition of Care/Continuity of Care Form-AZ Medicare English | Spanish

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

External Review Request Form

Physician Certification Expedited External Review Request Form

Physician Certification Experimental or Investigational Denials Form

Cigna Home Delivery Pharmacy Prescription Order Form

Pharmacy Claim Form(Not for Medicare Customers — see Medicare Pharmacy Claim Form)

Pharmacy Claims - Helpful Hints

Medicare-B Assignment of Benefits

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

External Review Request Form

Physician Certification Expedited External Review Request Form

Physician Certification Experimental or Investigational Denials Form

Cigna Vision Claim Forms: English | Spanish

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

Indemnity Vision (medical) claim

Behavioral Health Customer Claim Form

Indiana Specific Forms

Indiana Prior Authorization Form

Maryland Specific Forms

Maryland Uniform Treatment Plan Form

Massachusetts Specific Forms

Massachusetts Prior Authorization Form

Massachusetts Prior Authorization Form – Transcranial Magnetic Stimulation

New Mexico Specific Forms

New Mexico Prior Authorization Form

Vermont Specific Forms

Uniform Medical Prior Authorization

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

External Review Request Form

Physician Certification Expedited External Review Request Form

Physician Certification Experimental or Investigational Denials Form

West Virginia Specific Forms

West Virginia Prior Authorization Form

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

Accidental Injury claim form

Critical Illness claim form

Hospital Care claim form

Wellness Incentive claim form

Please submit your claim through New York Life.

• Care for family member
  • Claim Form for Benefits PFL 1
    
• Military Leave
  • Claim Form for Benefits PFL 1
  • Certification of Military Leave PFL 5
    
• Intermittent Absence Time Tracking Form

• Certification of Health Care Provider for Employee's Own Illness
  
• Certification of Health Care Provider for Care of a Family Member
• Bonding Leave
  • Birth
  • Adoption
  • Foster

Debit Card Validation

FSA Dependent Care Reimbursement

Dependent Care FSA Reimbursement Helpful Hints

FSA Reimbursement

HRA Reimbursement

FSA and HRA Reimbursement Helpful Hints

Authorization

Healthy Working Life FAQ and Referral Form