Customer Forms

Medical 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 / Continuity of Care (without Mental Health) Forms: English | Spanish | Chinese

Transition of Care / Individual and Family Plans
Update your Health Plan coverage-Spouse
Update your Health Plan coverage-Child
Update your Health Plan coverage-Medicare
Update your Health Plan coverage-Duplicate

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

Colorado Specific Forms

CO Customer Appeal Request Form

Hawaii Specific Forms

Disclosure For Conflicts of Interest Evaluation FormHI Request for External Review FormHIPAA Authorization for Release of Information Form

Indiana Specific Forms

Indiana Prior Authorization Form

Massachusetts Specific Forms

MA Cardiac Imaging Prior Authorization FormMA CT/CTA/MRI/MRA Prior Authorization FormMA 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 RepresentativeExternal Review Request FormPhysician Certification Expedited External Review Request FormPhysician Certification Experimental or Investigational Denials Form

West Virginia Specific Forms

West Virginia Prior Authorization Form

Dental Forms

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

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 RepresentativeExternal Review Request FormPhysician Certification Expedited External Review Request FormPhysician Certification Experimental or Investigational Denials Form

Pharmacy Forms

Cigna Home Delivery Pharmacy Prescription Order Form

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

Pharmacy Claims - Helpful HintsMedicare-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 RepresentativeExternal Review Request FormPhysician Certification Expedited External Review Request FormPhysician Certification Experimental or Investigational Denials Form

Vision Forms

Cigna Vision Claim Forms: English | Spanish

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

Indemnity Vision (medical) claim

Behavioral Forms

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 RepresentativeExternal Review Request FormPhysician Certification Expedited External Review Request FormPhysician 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.

Uniform Medical Prior Authorization Form

Disability/Accident/Life Forms

Submit a Disability Claim Long Term Disabilty-Educator Plan Disability Disclosure Authorization Submit a Life and Accidental Death & Dismemberment Claim How to Submit a Life and Accident Claim Proof of Loss Job Aid Funeral Assignment Job Aid Life and Accidental Death Physician’s Statement of Disability Total and Permanent Disability / Waiver of Premium Dismemberment Accelerated Death Benefits Disclosure Auth for Deceased Insured Claim Disclosure Auth for Living Insured Claim State Income Tax Withholding Request for Federal Income Tax Withholding Electronic Fund Transfer Authorization Verbal Authorization Information Accidental Dismemberment or Disability GUL Cignaassurance Claim Form GUL Non-Cignaassurance Claim Form Customer Authorization Form

Accidental Injury, Critical Illness, Hospital Care and
Wellness Incentive Claim Forms

Submit an Online Accidental Injury, Critical Illness, Hospital Care, or Wellness Claim

Accidental Injury claim form

Critical Illness claim form

Hospital Care claim form

Wellness Incentive claim form

Bonding Leave

Claim form for benefits

Certification form for bonding leave

Care for family member

Claim form for benefits

Certification and patient release form for Care of family member leave

Military Leave

Claim form for benefits

Certification for military leave

Intermittent Absence Time Tracking Form

Intermittent Absence Time Tracking Form

Cigna Choice Fund HRA/FSA Claim Forms

Debit Card Validation FSA Dependent Care Reimbursement Dependent Care FSA Reimbursement Helpful Hints FSA Reimbursement HRA Reimbursement FSA and HRA Reimbursement Helpful Hints

International Forms

Login to Cigna Envoy for Cigna Global Health Benefits forms.

Healthy Working Life Forms

Authorization

Healthy Working Life FAQ and Referral Form