Loading...Download Cigna Medical Claim Form (Form 591692 c). This is a medical claim for for Cigna Medical Services. This form would need to be used if your physician’s office does not file claims for you. If you are paying out of pocket and need to file a claim for reimbursement, complete and submit.
How To Write
Step 1 – Section 1 – Primary Customer Information: Primary Customer Complete This Section:
- A1. Primary Customers Last Name
- First Name
- Middle Initial
- A2. Gender (check one)
- b. Date Of Birth mm/dd/yyyy
- c. Primary Customer’s Mailing Address – Number, Street
- City
- State
- Zip Code
- Daytime Phone Number
- Is This a Change of Address? (if so, change must be reflective in area C.
- d.Cigna ID Number or Primary Customer Social Security Number
- e. Account Number (located on the front of your card)
- f. Employer Name
- g. Primary Customer Status (check one)
- Effective Date – mm/dd/yyyy
Step 2 – Section 2 – Patient Information – Complete This Section Only if The Patient is Not the Primary Customer:
- a. Patient’s Name- Last name
- First Name
- Middle Initial
- b. Relationship to Primary Customer (check one)
- c. Date of Birth mm/dd/yyyy
- d. Gender (check one)
- e. Patient’s Address – If Different Than Primary Customer Address – Number, Street
- City
- State
- Zip Code
- f. At The Time Medical Service Was Provided Was The Patient – (check one)
Step 3 – Section 3 – Accidental Occupation Claim Information – Only complete this section if you are filing the claim because of an accident or occupational, work related, injury or illness
- a. Accident or Illness Due To Employment? (check one)
- b. Injury Due To Auto Accident? (check one)
- c. Description of How Accident or Work-Related Illness/Injury Occurred (briefly explain)
- d. Date of Accident Or Beginning Of Illness (mm/dd/yyyy)
- e. Are You Or Your Dependents Filing A Claim Or Lawsuit Against A Third Party, Including An Insurance Company In Order To Recover The Cost Of Expenses Incurred As A Result Of This Accident Or Illness? (check one) If Yes, Name of Third Party.
Step 4 – Section 4 – Family/Other Coverage Information – Only complete this section if claim is for a dependent and/or other coverage is in effect
- a. Spouse Employed? (check one)
- If No- Has Spouse Been Employed In The Past 12 Months? (check one)
- b. Name of Spouse – Last Name
- First Name
- Middle Initial
- Spouse’s Date of Birth (mm/dd/yyyy)
- c. Name of Spouse Employer
- Address of Spouse Employer – Number, Street
- City
- State
- Zip Code
- Telephone Number (with area code)
- d. Is The Patient Covered Under Another Health Insurance Plan? – (check one) If Yes, provide the name of the other Health Insurance Company
- Effective Date of Coverage (mm/dd/yyyy)
- Policy Number
- Type of Plan – HMO or PPO- If Known
Step 5 – Certification
- Carefully read the information in the paragraph prior to signing this document – Once you have read and if you agree –
- Primary Customer’s Signature mm/dd/yyyy
Step 6 – Payment Instructions – Read the statement above the signature line – if you understand and agree –
- Primary Customer’s Signature
- Date mm/dd/yyyy
Be advised that Cigna pays directly to the provider with or without customer signature