Customer Forms

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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

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 Forms

Dental Claim Form English | Spanish

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

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

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

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

Disability/Accident/Life Forms

Long Term Disabilty-Educator Plan

Disability Disclosure Authorization

How to Submit a Life and Accident Claim Job Aid 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) Indemnity and
Health Screening/Wellness Claim Forms
Bonding Leave
Care for family member
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

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