Forms

Member Forms

	Medical Forms

	Request a Medical ID card (online form)
	Change Primary Care Physician (online form)
	Medical Claim Appeal Requests (PDF 123k)
	Medical Claim Form (PDF 74k)
	Transition of Care / Continuity of Care with Mental Health (PDF 3.6MB) (PDF) (PDF) Transition of Care / Continuity of Care without Mental Health (PDF 3.6MB)
	Update your Health Plan coverage - Spouse (PDF 90k)
	Update your Health Plan coverage - Child (PDF 74k)
	Update your Health Plan coverage - Medicare (PDF 122k)
	Update your Health Plan coverage - Duplicate (PDF 91k)

	CIGNA Choice Fund HRA/FSA Claim Forms
	Debit Card Validation (PDF 425k)
	FSA Dependent Care Reimbursement (PDF 109k)
	FSA Reimbursement (PDF 172k)
	HRA Reimbursement (PDF 172k)

	California-specific Forms
	California-specific Plan Information
	CA Online Grievance Form (online form)
	CA-Grievance-Brochure (PDF) (PDF) (PDF)
	CA Medical Grievance Form (PDF) (PDF) (PDF)
	CA Dental Grievance Form (PDF) (PDF) (PDF)
	CA Behavioral Health Grievance Form (PDF) (PDF) (PDF)
	CA Continuity of Care Form (PDF) (PDF) (PDF)
	CA Transition of Care Form (PDF) (PDF) (PDF)
	Language Assistance Disclosure (PDF)

	Dental Forms
	Dentist Directory Request (online form)
	Patient Charge Schedule Request (online form)
	Dental Claim (PDF 1.4M)

	Vision Forms
	CIGNA Vision claim (PDF 53k)
	Indemnity Vision (medical) claim (PDF 58k)

	Pharmacy Forms
	Angiotensin Receptor Blockers (ARB) (PDF 29k)
	Antifungal Coverage form (PDF 53k)
	Compounds (PDF 32k)
	DACON Coverage (PDF 153k)
	Erectile Dysfunction Coverage (PDF 38k)
	Insulin Pens (PDF 29k)
	Mandatory Mail Order Exception Form (PDF 28k)
	Narcotic Medications (PDF 34k)
	Pharmacy Claim Form (PDF 63k)
	Medication Prior Authorization (PDF 154k)
	Medicare Pharmacy Claim Form (PDF 197k)
	Tel-Drug Profile (PDF 154k)
	Selzentry (PDF 29k)
	Singulair (PDF 29k)
	Tamiflu/Relenza (PDF 32k)
	Tykerb (PDF 28k)
	Weight Management Medications (PDF 28k)
	Specialty (Injectable) Drugs:

	Disability/Accident/Life Forms

	Short-term Disability (PDF)
	Long-term Disability (PDF)
	Submit a Disability Claim (online form)
	Disability Disclosure Authorization (PDF)
	Submit a Life and Accident Claim (online form)
	Life and Accident Disclosure Authorization (PDF)
	Physicians Statement of Disability (PDF)
	Disability Disclosure (PDF)
	Life & Accident (PDF)
	Accidental Death (PDF)
	Dismemberment (PDF)
	Accelerated Death benefits (PDF)
	Disclosure Auth for Deceased Insured Claim (PDF 9k)
	Disclosure Auth for Living Insured Claim (PDF 9k)
	State Income Tax Withholding (PDF)
	Request for Federal Income Tax Withholding (PDF)
	Electronic Fund Transfer Authorization (PDF 13k)
	Verbal Authorization Information (PDF 11k)
	Re-Employment Solutions
	CIGNA Re-Employment Solutions - Employee (PDF 138k)
	CIGNA's Re-Employment Solutions - Brokers (PDF 131k)

	International Forms
	CIGNA International Expatriate Benefits Member Form Center

	Behavioral Care Forms
	Behavioral Health Member Claim Form (PDF)

	Privacy Forms
	Request to Access Health Care Information (PDF) (PDF) (PDF)
	Request to Amend Private Health Information (PDF) (PDF) (PDF)
	Request for Accounting (PDF) (PDF) (PDF)
	Request for Restriction of Use (PDF) (PDF) (PDF)
	Request for Confidential Communications (PDF) (PDF) (PDF)

	Request for Personal Representative (PDF) (PDF) (PDF)

	Statement of Disagreement - Amendment Request (PDF) (PDF) (PDF)

	Change/Revoke Request (PDF) (PDF) (PDF)

	Authorization for Disclosure of Private Health Information (PDF) (PDF) (PDF)