Activate your myCigna account for access to all plan details and live, 24/7 support.
This is a selection of important forms available to you as a customer. To view all your forms, log in to myCigna.
*For a Behavioral Health Appeal Form, please see the Behavioral Forms section below.
Direct Member Reimbursement (DMR): English [PDF]
Appointment of Representative Form: English [PDF]
Appointment of Representative Form (fillable version): English [PDF]
Transition of Care / Continuity of Care (with Mental Health) Forms: English [PDF] | Spanish [PDF] | Chinese [PDF]
For California-specific forms and plan information, visit our Cigna Healthcare in California page.
Arizona Specific Forms
Colorado Specific Forms
Florida Specific Forms
Hawaii Specific Forms
Indiana Specific Forms
Massachusetts Specific Forms
Michigan Specific Forms
Nebraska Specific Forms
New Jersey Specific Forms
New Mexico Specific Forms
Texas Specific Forms
Vermont Specific Forms
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.
West Virginia Specific Forms
Transition of Care/Continuity of Care Form English [PDF] | Spanish [PDF] | Chinese [PDF]
Transition of Care/Continuity of Care Form-AZ Medicare English [PDF] | Spanish [PDF]
For California-specific forms and plan information, visit our Cigna Healthcare in California page.
New Hampshire Specific Forms
Outline of Coverage Form - Dental
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.
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.
Cigna Vision (VSP) Claim Forms: English [PDF] | Spanish [PDF]
Cigna Vision serviced by EyeMed Out of Network Claim Forms: English [PDF] | Spanish [PDF]
Cigna Vision serviced by EyedMed Exception Claim Forms: English [PDF] | Spanish [PDF]
New Hampshire Specific Forms
Outline of Coverage Form - Vision
Behavioral Appeal Request (printable version): English [PDF] | Spanish [PDF] | Chinese [PDF]
Behavioral Appeal Request (filllable version): English [PDF] | Spanish [PDF] | Chinese [PDF]
*For a Medical Appeal Form, please see the Medical Forms section above.
Behavioral Appointment of Representative Form: English [PDF]
Behavioral Appointment of Representative Form (fillable version): English [PDF]
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.
For California-specific forms and plan information, visit our Cigna Healthcare in California page.
Care for family member
Military Leave
Bonding Leave
Form 1095-B provides important tax information about your health coverage.
To request your 1095-B form, you can:
If you have questions about your 1095-B form contact Cigna Healthcare SM at .
For forms related to privacy and legal matters, visit the Privacy Forms page.
You can find Summary Benefits of Coverage and Outlines of Coverage for medical and dental plans, past and present.
The Dental Oral Health Integration Program
This program provides reimbursement for certain eligible dental procedures for customers with qualifying medical conditions. Customers must enroll in the program prior to receiving dental services to be eligible for reimbursement. Reimbursement is applied to and subject to any applicable annual benefits maximum. See your plan documents or contact Cigna Healthcare for complete program details.
The State of Colorado Notice-Access Plan
You may request a copy of our Access Plan. The Access Plan is designed to disclose all the policy information required under Colorado law. It is available for your review upon request and explains 1) Who participates in our provider network; (2) how we ensure that the network meets the health care needs of our members; (3) how our provider referral process works: (4) how care is continued if providers leave our network; (5) what steps we take to ensure medical quality and customer satisfaction; (6) where you can go for information on other policy services and features.
Product availability may vary by location and plan type and is subject to change. All health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna Healthcare representative.
All Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc. and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of The Cigna Group Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT). The Cigna Healthcare name, logo, and other Cigna Healthcare marks are owned by Cigna Intellectual Property, Inc. This website is not intended for residents of Arizona and New Mexico.
Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna Healthcare website. Cigna Healthcare may not control the content or links of non-Cigna Healthcare websites. Details
La aseguradora publica el formulario traducido para fines informativos y la versión en inglés prevalece para fines de solicitud e interpretación.
The insurer is issuing the translated form on an informational basis and the English version is controlling for the purposes of application and interpretation.