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  • Home Medicare Member Resources and Services Customer Forms

    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:

    Questions? Reach us at:

    Medicare Advantage Plans: (TTY 711)

    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): (TTY 711)

    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): (TTY 711)

    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 Forms*

    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 (), 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]

    Credit Card Form [PDF]

    Last Updated 10/01/2023

    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.

    Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona

    Coverage Determination Form [PDF]

    Online Form

    Last Updated 10/01/2022

    If not using online form, send to:

    Cigna Healthcare
    8455 University Place #HQ2L-04
    St. Louis, MO 63121
    Or fax to:

    Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

    Coverage Determination Form [PDF]

    Online Form

    Last Updated 10/01/2022

    If not using online form, send to:

    Cigna Healthcare
    8455 University Place #HQ2L-04
    St. Louis, MO 63121
    Or fax to:

    Medicare Part D Prescription Plans

    Coverage Determination Form [PDF]

    Online Form

    Last Updated 10/01/2022

    If not using online form, send to:

    Cigna Healthcare
    8455 University Place #HQ2L-04
    St. Louis, MO 63121
    Or fax to:

    Dental Forms

    Dental Reimbursement Claim Form

    Use this form when you want to get reimbursed for a dental benefit that you have already paid for. Once you’ve completed the form, print and mail it to one of the following addresses, depending on which plan you’re enrolled in. Please note that the benefit does not apply to all plans. Review your Evidence of Coverage (EOC) for benefit details.

    Dental Reimbursement Claim Form [PDF]

    Last Updated 10/01/2022

    For Cigna Healthcare Dental Allowance Plans:
    Cigna Healthcare Dental-Reimbursement
    PO Box 188037
    Chattanooga, TN 37422-8037

    For Cigna Healthcare DHMO Plans:
    Cigna Healthcare Dental-Reimbursement
    PO Box 188045
    Chattanooga, TN 37422-8045

    If your plan’s mailing address is not listed, call Customer Service at the phone number listed on your ID card.

    Medical Payment Appeal Forms

    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
    P.O. Box 188081
    Chattanooga, TN 37422

    Call: , TTY 711, 8 am – 8 pm, 7 days a week.

    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 01/23/2024

    Medical Pre-Service Appeal Forms

    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
    P.O. Box 188081
    Chattanooga, TN 37422

    Call: , TTY 711, 8 am - 8 pm, 7 days a week.

    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 01/23/2024

    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
    P.O. 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]

    Last Updated 01/10/2024

    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].

    Last Updated 01/10/2024

    Print and send form to:

    Cigna Healthcare
    Attn: DMR
    PO Box 1004
    Nashville, TN 37202

    Prescription Drug Claim (Reimbursement) Forms

    Use when you want to get reimbursed for a medication that you have already paid for.

    Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona

    Drug Claim Form [PDF]

    Last Updated 10/01/2022

    Print form and send to:
    Cigna Healthcare
    Attn: Medicare Part D
    P.O. Box 14718
    Lexington, KY 40512-4718

    Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

    Drug Claim Form [PDF]

    Last Updated 10/01/2022

    Print form and send to:
    Cigna Healthcare
    Attn: Medicare Part D
    P.O. Box 14718
    Lexington, KY 40512-4718

    Medicare Part D Prescription Plans

    Drug Claim Form [PDF]

    Last Updated 10/01/2022

    Print form and send to:
    Cigna Healthcare
    Attn: Medicare Part D
    P.O. 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 01/23/2024

    Accounting of Protected Health Information Disclosure Form [PDF]

    Use when you want to request accounting of your protected health information (PHI).

    Last Updated 01/23/2024

    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 01/23/2024

    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 01/23/2024

    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 01/23/2024

    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 01/23/2024

    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.

    Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona

    Redetermination Form [PDF]

    Online Form

    Last Updated 10/01/2022

    If not using online form, send to:
    Cigna Healthcare
    Medicare Clinical Appeals
    P.O. Box 66588
    St. Louis, MO 63166-6588
    Or fax to:

    Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

    Redetermination Form [PDF]

    Online Form

    Last Updated 10/01/2022

    If not using online form, send to:
    Cigna Healthcare
    Medicare Clinical Appeals
    P.O. Box 66588
    St. Louis, MO 63166-6588
    Or fax to:

    Medicare Part D Prescription Plans

    Redetermination Form [PDF]

    Online Form

    Last Updated 10/01/2022

    If not using online form, send to:
    Cigna Healthcare
    Medicare Clinical Appeals
    P.O. Box 66588
    St. Louis, MO 63166-6588
    Or fax to:

    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
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  • Medicare Advantage and Medicare Part D Policy Disclaimers

    Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna Healthcare names, logos, and marks, including THE CIGNA GROUP and CIGNA HEALTHCARE are owned by The Cigna Group Intellectual Property, Inc. Subsidiaries of The Cigna Group contract with Medicare to offer Medicare Advantage HMO and PPO plans and Part D Prescription Drug Plans (PDP) in select states, and with select State Medicaid programs. Enrollment in a Cigna Healthcare product depends on contract renewal.

    To file a marketing complaint, contact Cigna Healthcare or call 1-800-MEDICARE (), 24 hours a day, 365 days a year, TTY . Please include the agent/broker name if possible.

    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 or Loyal American 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: CNHIC-MS-AA-A-KS, CNHIC-MS-AO-A-KS; Plan F: CNHIC-MS-AA-F-KS, CNHIC-MS-AO-F-KS; Plan G: CNHIC-MS-AA-G-KS, CNHIC-MS-AO-G-KS; Plan N: CNHIC-MS-AA-N-KS, CNHIC-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.

    Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna Healthcare website.

    Y0036_24_1037312_M | Page last updated 03/28/2024

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