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Customer Forms
Find the forms you may need to manage your Medicare plan.
These forms can help with your Medicare plan from Cigna HealthcareSM. As shown below, some forms can be sent online. To send a form through the web, simply click on the Online Form link and follow the instructions to enter the correct information.
A Note for Group-Sponsored Plans: Only forms with an asterisk (*) also have to do with group-sponsored plans. If you are in a Medicare group plan and need a group plan form, you can:
- Visit Group Plans Resources
- Call the phone number on your ID card
- Talk to your plan administrator
Questions? Reach us at:
Medicare Advantage Plans:
Oct. 1 - Mar. 31: 8 am - 8 pm, 7 days a week
April 1 - Sept. 30: Mon. - Fri., 8 am - 8 pm. Messaging service used weekends, after hours, and federal holidays.
Medicare Advantage Plans (Arizona only):
Oct. 1 - Mar. 31: 8 am - 8 pm (Arizona time), 7 days a week
April 1 - Sept. 30: Mon. - Fri., 8 am - 8 pm (Arizona time). Voicemail available on weekends and federal holidays.
Medicare Prescription Drug Plans (PDP):
8 am - 8 pm, 7 days a week. Our automated phone system may answer your call during weekends from April 1 - Sept. 30.
Appointment of Representative Form*
Use when you want someone other than yourself to stand for you in all matters that have to do with your coverage determination or appeal (see below).
Appointment of Representative Form [PDF]
Last Updated 10/01/2022
You’ll send this form to the same place where you are sending your grievance, coverage determination, or appeal.
If you need more help, you can:
- Reach out to your Medicare plan
- Call 1-800-MEDICARE 1 (800) 633-4227, 24 hours a day, 7 days a week (except some federal holidays)
- Contact Us
Automatic Premium Payment Authorization Forms*
Use when you want to allow us to automatically take your premium out of your bank account or charge your premium payment to your credit card.
Medicare Advantage Plans
Sign up for automatic premium payments through your myCigna account.
Medicare Part D Prescription Plans
Automatic Payment Form (Recurring Direct Debit) [PDF]
Last Updated 01/11/2024
Print and send form to:
Cigna Healthcare Medicare Prescription Drug Plans
PO Box 269005
Weston, FL 33326-9927
Coverage Determination/Exceptions Request Forms*
Use when you want to ask for coverage for a medication that is not covered by your plan or has limits on its coverage.
Coverage Determination Form [PDF]
Last Updated 03/04/2025
If not using online form, send to:
Cigna Healthcare
Attn: Medicare Reviews
PO Box 66571
St. Louis, MO 63166-6571
Or fax to: 1 (866) 845-7267
Dental Forms
Dental Reimbursement Claim Form
You can use either of the Dental Reimbursement Claim Forms below when you want to get reimbursed for a dental benefit that you have already paid for.
- Medicare Advantage Dental Reimbursement Claim Form [PDF]
- American Dental Association (ADA) Dental Reimbursement Claim Form [PDF]
To request reimbursement, print and complete either form, along with your proof of payment and itemized statement. If you need assistance with filling out the form, you can bring it to your provider's office.
For Cigna Healthcare Dental Allowance Plans, send to:
Cigna Healthcare Dental-Reimbursement
PO Box 188037
Chattanooga, TN 37422-8037
For Cigna Healthcare DHMO Plans, send to:
Cigna Healthcare Dental-Reimbursement
PO Box 188045
Chattanooga, TN 37422-8045
Regardless of which option you choose, please note that it can take up to 60 days for a reimbursement form to be processed, and this benefit does not apply to all plans. Review your Evidence of Coverage (EOC) for benefit details.
Medical Payment Appeal Form
You or your appointed representative may ask for an appeal when you want to us to review coverage again, after your first request has been denied. This may be for a medical item or service that you have already received and paid for.
You can call, fax, or write to us.
Find out more about how appeals work
Write:
Cigna Healthcare Medicare
Attn: Appeals
PO Box 188081
Chattanooga, TN 37422
Call:
April 1 - September 30: Monday - Friday 8 am - 8 pm (messaging service used weekends, after hours, and federal holidays).
Fax:
Cigna Medicare Advantage Member and Representative Claim Appeal Form [PDF]
Last Updated 04/16/2024
Medical Pre-Service Appeal Form
You or your appointed representative may ask for an appeal when you want to have us re-review coverage of a medical item or service that you have not yet received, after it has been denied through the first organization determination process.
You can call, fax, or write to us.
Write:
Cigna Healthcare
Attn: Appeals
PO Box 188081
Chattanooga, TN 37422
Call:
April 1 - September 30: Monday - Friday 8 am - 8 pm (messaging service used weekends, after hours, and federal holidays).
Fax:
Cigna Medicare Advantage Member and Representative Authorization Appeal Form [PDF]
Last Updated 04/16/2024
Medical Reimbursement Claim Forms*
Medicare Advantage Plans - Except Arizona HMO
Medical Reimbursement Claim Form [PDF]
Last Updated 10/01/2022
Print and send form to:
Cigna Healthcare
Attn: Claims
PO Box 20002
Nashville, TN 37202-9640
Medicare Advantage Plans - Arizona HMO Only
For claims with service date in 2023, please fill out the 2023 Medical Reimbursement Claim Form [PDF] for Medicare Advantage Plans in Arizona.
Last Updated 02/15/2024
Print and send form to:
Cigna Healthcare
Attn: DMR
PO Box 38639
Phoenix, AZ 85063-8639
For claims with service date in 2024, please fill out the 2024 Medical Reimbursement Claim Form [PDF] for Medicare Advantage Plans in Arizona.
Last Updated 02/15/2024
Print and send form to:
Cigna Healthcare
Attn: DMR
PO Box 1004
Nashville, TN 37202
Medicare Prescription Payment Plan Request Form
Use this form to opt-in for the Medicare Prescription Payment Plan. Once you’ve completed the form, mail it to the address below. Please note that this voluntary program only applies to Part D Prescription Drug Plans and Medicare Advantage Plans with Part D (MAPD).
Medicare Prescription Payment Plan Request Form [PDF]
Last Updated 10/01/2024
If not using online form, send to:
Express Scripts MPPP
PO Box 801101
Kansas City, MO 64180-1101
Prescription Drug Claim (Reimbursement) Form
Use when you want to get reimbursed for a medication that you have already paid for.
Last Updated 02/22/2024
Print form and send to:
Cigna Healthcare
Attn: Medicare Part D
PO Box 14718
Lexington, KY 40512-4718
Privacy Forms
Privacy forms help protect your health data. To use a form, please print and send to the address noted on the form.
Access to Health Care Information Form [PDF]
Use when you want to request access to protected health information that we have created or received.
Last Updated 10/01/2024
Accounting of Protected Health Information Disclosure Form [PDF]
Use when you want to request accounting of your protected health information (PHI).
Last Updated 10/01/2024
Authorization for Disclosure Form [PDF]
Use when you want to allow the disclosure of specific protected health information to a specific person or entity.
Last Updated 10/01/2024
Confidential Communication Form [PDF]
Use when you want to have messages with protected health information sent to a different address than the one we have on file.
Last Updated 10/01/2024
If you live in Oregon or Vermont, please use one of the forms below:
Confidential Communication Form - Oregon [PDF]
Confidential Communication Form - Vermont [PDF]
Disagreement/Denial Amendment Form [PDF]
Use when you want to provide your disagreement to denial of your request to amend your protected health information (PHI).
Last Updated 01/23/2024
Protected Health Information Amendment Form [PDF]
Use when you want to request an amendment of your protected health information (PHI).
Last Updated 10/01/2024
Restriction/Disclosure of Protected Health Information Form [PDF]
Use when you want to request a restriction on the use or disclosure of your protected health information (PHI).
Last Updated 10/01/2024
Redetermination Request Forms*
Use when you want us to re-review coverage of a medication or a payment/reimbursement request after it has been denied.
Last Updated 03/04/2025
If not using online form, send to:
Cigna Healthcare
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to: 1 (866) 593-4482
24/7 Access to Your Plan
myCigna gives you one-stop access to your coverage, premium payments, ID cards, and more. Help and support is available 24/7/365.
24/7 Access to Your Plan
myCigna gives you one-stop access to your coverage, premium payments, ID cards, and more. Help and support is available 24/7/365.
*Indicates forms also applicable for Group-Sponsored plans
Customer Plan Links
Audiences
Other Cigna Healthcare Websites
Medicare Links
Medicare Advantage and Medicare Part D Policy Disclaimers
Cigna Healthcare products and services are provided by or through operating subsidiaries of Health Care Service Corporation, a Mutual Legal Reserve Company and Cigna Health & Life Insurance Company, a subsidiary of The Cigna Group. The Cigna names, logos and marks are owned by Cigna Intellectual Property, Inc. and used under license. Cigna Healthcare is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna Healthcare depends on contract renewal. © Copyright 2025 Health Care Service Corporation. All Rights Reserved.
To file a marketing complaint, contact Cigna Healthcare or call 1-800-MEDICARE (
Medicare Supplement Policy Disclaimers
Medicare Supplement website content not approved for use in: Oregon.
AN OUTLINE OF COVERAGE IS AVAILABLE UPON REQUEST. We'll provide an outline of coverage to all persons at the time the application is presented.
Our company and agents are not connected with or endorsed by the U.S. Government or the federal Medicare program. This is a solicitation for insurance. An insurance agent may contact you. Premium and benefits vary by plan selected. Plan availability varies by state. Medicare Supplement policies are underwritten by American Retirement Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Insurance Company, Cigna National Health Insurance Company, Loyal American Life Insurance Company or Medco Containment Life Insurance Company. Each insurer has sole responsibility for its own products.
The following Medicare Supplement Plans are available to persons eligible for Medicare due to disability: Plan A in Arkansas, Connecticut, Indiana, Maryland, Oklahoma, Rhode Island, Texas, and Virginia; Plans A, F, and G in North Carolina; and Plans C and D in New Jersey for individuals aged 50-64. Medicare Supplement policies contain exclusions, limitations, and terms under which the policies may be continued in force or discontinued. For costs and complete details of coverage, contact the company.
This website is designed as a marketing aid and is not to be construed as a contract for insurance. It provides a brief description of the important features of the policy. Please refer to the policy for the full terms and conditions of coverage.
In Kentucky, Plans A, F, G, HDG, N are available under Cigna National Health Insurance Company, Plans A, F, G, HDF, N are available under Cigna Health and Life Insurance Company and Plans A, B, C, D, F, G, N are available under Loyal American Life Insurance Company.
Kansas Disclosures, Exclusions and Limitations
Medicare Supplement Policy Forms: Plan A: CIC-MS-AA-A-KS, CIC-MS-AO-A-KS; Plan F: CIC-MS-AA-F-KS, CIC-MS-AO-F-KS; Plan G: CIC-MS-AA-G-KS, CIC-MS-AO-G-KS; Plan HDG: CIC-MS-AA-HDG-KS, CIC-MS-AO-HDG-KS; Plan N: CIC-MS-AA-N-KS, CIC-MS-AO-N-KS
Exclusions and Limitations:
The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:
(1) the Medicare Part B Deductible;
(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;
(3) any services that are not medically necessary as determined by Medicare;
(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;
(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;
(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or
(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.