Loading...Download the Cigna Medical Claim | Form 591692c that can be used with all Cigna medical plans only. One must only use this form if the Doctor doesn’t file your claim for you. This form cannot be used to make claims for pharmacy nor would it be used for dental claims.
How To Write
Step 1 – Section 1 – Primary Customer Information –
- The information required here is for the actual person who carries the policy, not necessarily the patient. Complete the following:
- A1. – Primary Customer’s last name, first name, middle initial
- A2. – Gender (check the appropriate box)
- B – Date of Birth mm/dd/yyyy
- C – Primary Customer’s street address and number, city, state, zip code and daytime telephone number
- Is this a change of address? (check one)
- D – Cigna ID number or social security number
- E – Account number
- F – Employer name
- G – Primary customer status (check the appropriate box)
- Effective date mm/dd/yyyy
Step 2 – Section 2 – Patient Information –
- Complete this section only if the patient is not the primary carrier on this policy. If the primary customer is the patient, there is no need to fill out this section – Provide the following information:
- A – Patient’s last name, first name, middle initial
- B – Patient’s relationship to primary customer (check one)
- D – Gender (check one)
- E – Patient’s address (if different from the primary customer)City, State, Zip Code – Daytime Telephone
- Is this a change of address? (Check yes or no)
- D1 – Is the patient covered under another health insurance plan? – Check yes or no and provide a date the plan went into effect mm/dd/yyyy
- Is the patient covered under medicaire> (Check yes or no)
- If yes to either D1 or 2 and the other insurance company is primary, send this form and a copy of the explanation of benefits and itemized bill for the claim
Step 3 – Section 3 -Certification-
- Read the entire paragraph under the certification section. Once read, understood and agreed, the primary customer must provide signature and date mm/dd/yyyy
Step 4 – Section 4 – Payment Instructions –
This section will authorize Cigna to pay the provider directly. Once read, understood and agree the primary customer must provide signature and date of signature mm/dd/yyyy
If Cigna has a contract with the provider they will always pay them directly with or without signature. If you have already paid the provider, you must request a refund.