Customer Forms

Request a Medical ID card
Change Primary Care Physician
Medical Appeal Requests
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

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

Texas Specific Forms

Texas Standard Prior Authorization Request Form for Health Care Services

Vermont Specific Forms

Uniform Medical Prior Authorization

Virginia Specific Forms

External Review Request FormAppointment of Authorized RepresentativePhysician Certification Expedited External Review Request FormPhysician Certification Experimental or Investigational Denials Form

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)

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

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

Cigna Vision Claim Forms: English | Spanish

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

Indemnity Vision (medical) claim

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

Vermont Specific Forms

Uniform Medical Prior Authorization

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

Uniform Medical Prior Authorization Form

Short-term Disability Long-term Disability

• Submit a Disability Claim

Long Term Disabilty-Educator Plan

Disability Disclosure Authorization

• Submit a Life and Accidental Death & Dismemberment Claim

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, Injury or Disability Critical IllnessGroup Hospital Care Proof of Loss FormCritical Illness and Hospital Care Extension of Benefits and Waiver of Premium Proof of Loss Form GUL Cignaassurance Claim Form GUL Non-Cignaassurance Claim Form

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

Login to Cigna Envoy for Cigna Global Health Benefits forms.

Authorization

Healthy Working Life FAQ and Referral Form