2020 Cigna Customer Forms

Use when you want someone other than yourself to represent you in all matters concerning your coverage determination or appeal (see below).

Appointment of Representative Form
Nombramiento de un Representante

Send this form to the same location where you are sending your grievance, coverage determination, or appeal.

If you need more help, you can:

• Contact your Medicare plan
• Call 1-800-MEDICARE (1 (800) 633-4227, 24 hours a day, 7 days a week)
• Contact Us

Use when you want to authorize us to automatically deduct your premium from your bank account or charge your premium payment to your credit card.

Medicare Advantage Only Plans – Except Arizona

EFT Form – Except Kansas City and Arizona

EFT Form – Kansas City Only

Formulario de Transferencia Electrónica de Fondos

Print and send form to:

Cigna
Attn: MAS - Premium Billing
P.O. Box 20012
Nashville, TN 37202-9919

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

EFT Form – Except Kansas City and Arizona

EFT Form – Kansas City Only

Formulario de Transferencia Electrónica de Fondos

Print and send form to:

Cigna
Attn: MAS - Premium Billing
P.O. Box 20012
Nashville, TN 37202-9919

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

EFT Form

Formulario de Transferencia Electrónica de Fondos

Credit Card Form

Acuerdo de autorización para débito mensual con tarjeta de crédito

Print and send form to:

Cigna
Attn: Payment Control Department
P.O. Box 29030
Phoenix, AZ 85038

Medicare Part D Prescription Plans

Automatic Payment Form (Recurring Direct Debit)

Formulario de autorización de débito directo periódico

Credit Card Form

Acuerdo de autorización para débito mensual con tarjeta de crédito

Print and send form to:

Cigna Medicare Prescription Drug Plans 
PO Box 269005
Weston, FL 33326-9927

Use when you want to request coverage for a medication that is not covered by your plan or has limitations on its coverage.

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Coverage Determination Form

Online Form

Solicitud de determinación de cobertura para medicamentos con receta de medicare

If not using online form, send to:

Cigna 
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to: 1 (866) 845-7267

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Coverage Determination Form

Online Form

Solicitud de determinación de cobertura para medicamentos con receta de Medicare

If not using online form, send to:

Cigna
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to: 1 (866) 845-7267

Medicare Part D Prescription Plans

Coverage Determination Form

Online Form

Solicitud de determinación de cobertura para medicamentos con receta de Medicare

If not using online form, send to:

Cigna
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to: 1 (866) 845-7267

Use when you want to request reimbursement for covered dental expenses.

Note: Benefit does not apply to all plans. Please review your Evidence of Coverage (EOC) for benefit details.

Dental Claim Form

For mailing address, call Customer Service at the telephone number listed on your Cigna ID card.

You or your appointed representative may request an appeal when you want to have us reconsider coverage of a medical item or service that you have already received and paid for after your initial request has been denied.

You can call, fax, or write to us.
Find out more information about the appeals process.

Medicare Advantage Only Plans – Except Arizona

Write:

Cigna
Attn: Appeals
P.O. Box 24087
Nashville, TN 37202-4087

Call:1 (800) 668-3813, TTY 711, 8:00 am – 8:00 pm (Local time), 7 days a week. April 1 – September 30: Monday – Friday 8:00 am – 8:00 pm Local time (messaging service used weekends, after hours, and Federal holidays).

Fax:1 (800) 931-0149

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Write:

Cigna
Attn: Appeals
P.O. Box 24087
Nashville, TN 37202-4087

Call: 1 (800) 668-3813, TTY 711, 8:00 am – 8:00 pm Local time, 7 days a week. April 1 – September 30: Monday – Friday 8:00 am - 8:00 pm Local time (messaging service used weekends, after hours, and Federal holidays).

Fax: 1 (800) 931-0149

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Medical Payment Appeal Form

Online Form

If not using online form, send to:

Cigna
Attn: Medicare Appeal Department
PO Box 29030
Phoenix, AZ 85038
Or fax to: 1 (866) 567-2474

You or your appointed representative may request an appeal when you want to have us reconsider coverage of a medical item or service that you have not yet received after it has been denied via the initial organization determination process.

You can call, fax, or write to us.
Find out more information about the appeals process.

Medicare Advantage Only Plans – Except Arizona

Write:

Cigna
Attn: Precertification
P.O. Box 20002
Nashville, TN 37202-4087

Call: 1 (800) 668-3813, TTY 711, 8:00 am – 8:00 pm Local time, 7 days a week. April 1 – September 30: Monday – Friday 8:00 am – 8:00 pm Local time (messaging service used weekends, after hours, and Federal holidays).

Fax:1 (800) 931-0149

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Write:

Cigna
Attn: Appeals
P.O. Box 24087
Nashville, TN 37202-4087

Call: 1 (800) 668-3813, TTY 711, 8:00 am – 8:00 pm Local time, 7 days a week. April 1 – September 30: Monday – Friday 8:00 am – 8:00 pm Local time (messaging service used weekends, after hours, and Federal holidays).

Fax:1 (800) 931-0149

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Medical Pre-Service Appeal Form

Online Form

If not using online form, send to:

Cigna
Attn: Medicare Appeal Department
PO Box 29030
Phoenix, AZ 85038
Or fax to: 1 (866) 567-2474

Use when you want to request reimbursement of covered medical expenses.

Medicare Advantage Only Plans – Except Arizona

Medical Reimbursement Claim Form

Formulario de reclamo para solicitud de reembolso del miembro inscrito

Print and send form to:

Cigna
Attn: Claims
P.O. Box 20002
Nashville, TN 37202-9640

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Medical Reimbursement Claim Form

Formulario de reclamo para solicitud de reembolso del miembro inscrito

Print and send form to:

Cigna
Attn: Claims
P.O. Box 20002
Nashville, TN 37202-9640

Medicare Advantage Plans with Prescription Drug Coverage - Arizona

Medical Reimbursement Claim Form

Formulario de reclamo para solicitud de reembolso del miembro inscrito

Print and send form to:

Cigna
Attn: Medicare Claims
25500 Norterra Pkwy Building B
Phoenix, AZ 85085

Use when you want to request reimbursement for a medication that you have already paid for.

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Drug Claim Form

Forma de Reclamo de Medicamentos

Print form and send to:

Cigna 
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Drug Claim Form

Forma de Reclamo de Medicamentos

Print form and send to:

Cigna 
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718

Medicare Part D Prescription Plans

Drug Claim Form

Forma de Reclamo de Medicamentos

Print form and send to:

Cigna 
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718

Privacy forms help manage your protected health information. To use a form, please print and send to the address noted on the form.

Accounting of PHI Disclosures Form / Solicitud de historial de divulgaciones de información sobre la salud protegida
Use when you want an itemized list of each time we have disclosed your protected health information

Disagreement/Denial of Amendment Form / Manifestación de desacuerdo/Solicitud para que se envíe el rechazo de la solicitud de modificación
Use when you want to formally disagree with our denial of your request to amend your protected health information that we maintain.

Restriction of Use and Disclosure of PHI Form / Solicitud de restricción de uso y divulgación de Información sobre la salud protegida
Use when you want to request a restriction on the use and disclosure of your protected health information.

Authorization for Disclosure Form / Autorización de divulgación de Información sobre la salud protegida
Use when you want to authorize the disclosure of specific protected health information to a specific person or entity.

Amend Protected Health Information Form / Solicitud para modificar Información sobre la salud protegida
Use when you want to request an amendment to the protected health information that we maintain.

Confidential Communication Form / Solicitud de comunicaciones confidenciales
Use when you want to have communications containing protected health information sent to a different address than the one we have on file.

If you reside in Oregon or Vermont, please use one of the forms below:

Confidential Communication Form - Oregon

Confidential Communication Form - Vermont

Access to Health Care Information Form / Solicitud de acceso a Información sobre atención médica
Use when you want to request access to protected health information that we have created or received.

Confidentiality and Disclosure Protocol Forms for Victims of Domestic Violence
Request for Confidentiality

Request to Revoke a Reasonable Request

Medicare Advantage Plans

Permission To Discuss Limited Health Information With Family And Friends - Medicare Advantage / Permiso para Conversar sobre Información sobre la Salud Limitada con Familiares y Amigos de Medicare Advantage
Use when you want to give permission to Cigna to discuss limited information about your Medicare Advantage Plan with family and friends.

Medicare Part D Prescription Plans

Permission To Discuss Limited Health Information With Family And Friends - Part D / Permiso para Conversar sobre Información sobre la Salud Limitada con Familiares y Amigos de Medicare Parte D
Use when you want to give permission to Cigna to discuss limited information about your Cigna Medicare Prescription Drug Plan with family and friends.

Use when you want us to reconsider 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

Online Form

Solicitud de nueva determinación de denegación de un medicamento con receta de Medicare

If not using online form, send to:

Cigna
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to: 1 (866) 593-4482

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Redetermination Form

Online Form

Solicitud de nueva determinación de denegación de un medicamento con receta de Medicare

If not using online form, send to:

Cigna
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to: 1 (866) 567-2474

Medicare Part D Prescription Plans

Redetermination Form

Online Form

Solicitud de nueva determinación de denegación de un medicamento con receta de Medicare

If not using online form, send to:

Cigna
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to: 1 (866) 593-4482