Health Care Claim Forms

Health Care Claim Forms

Find claim forms for medical, dental, family leave, and more.

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

Need help finding information?

Please call 1 (800) 997-1654 Monday – Friday, 9 am - 5 pm, ET. 

If you are an individual with a disability and need assistance to access Cigna’s services, you can call us at 1 (800) 853-2713 (TTY: 711) Monday - Friday, 9 am - 5 pm, ET.

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.