Patient Charge Schedule Request

Use this form to request a CIGNA Dental Care patient charge schedule.

Patient Charge Schedules are available to CIGNA Dental Care members only. If you have PPO or Traditional Indemnity coverage, please contact your employee relations office or your provider to obtain a benefit schedule.

 

*Indicates required field
 

Your Information

* First Name:

* Last Name:

*Daytime Phone:

   Extension:

* E-mail Address:
 

(Please verify that your e-mail address is correct)
 

Employee Information

* Employee Name:

* CIGNA ID Number:

*Street Address:

* City:

*State:

*Zip/Postal Code:

*How would you like to receive your charge schedule?

E-mail

Fax

    *Fax Number:   

Mail