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Cigna Medical Claim Form


Cigna Medical Claim Form
Cigna Medical Claim Form
Member Claim Form
COBRA*
591692a Rev. 10/2008
FAMILY/OTHER COVERAGE INFORMATION:
Complete only if claim is for a dependent and/or other coverage is in effect
NOTE:
X
NAME OF HEALTH INSURANCE COMPANY EFFECTIVE DATE OF COVERAGE
EMPLOYEE INFORMATION: Employee complete this section
If yes, provide:
X
POLICY NUMBER
TYPE OF PLAN (HMO OR PPO) IF KNOWN
C. DESCRIPTION OF HOW ACCIDENT OR WORK RELATED ILLNESS/INJURY OCCURRED
PATIENT INFORMATION: Complete only if patient is other than employee
ACCIDENT/OCCUPATIONAL CLAIM INFORMATION:
Complete only if claim is a result of an accident or occupational (work related) illness/injury
YES NO
NOYES
NOYES
NOYES
NO If yes, Name of Third Party:
F. EMPLOYER NAME
TELEPHONE #
A. EMPLOYEE’S NAME (Last Name, First Name, Middle Initial)
E. ACCOUNT NO. (on the front of your CIGNA ID card)
YES
OtherChild
NO
D. CIGNA ID NUMBER OR EMPLOYEE SOCIAL SECURITY NUMBER
(on the front of your CIGNA ID card)
YES
SPOUSE EMPLOYED
A. PATIENT’S NAME (Last Name, First Name, Middle Initial)
E. PATIENT’S ADDRESS - IF DIFFERENT THAN EMPLOYEE ADDRESS (No., Street)
SPOUSE’S DATE OF BIRTHIF NO, HAS SPOUSE BEEN EMPLOYED
DURING LAST 12 MONTHS
B. INJURY DUE TO
AUTO ACCIDENT
DISABLED*
IS THIS A CHANGE OF ADDRESS
(Note: address must also be changed with Employer)
A. ACCIDENT OR ILLNESS
DUE TO EMPLOYMENT
B. RELATIONSHIP TO EMPLOYEE
STUDENT FULL-TIME
*EFFECTIVE DATEG. EMPLOYEE STATUS
Please be aware that if the provider of service holds a contract with CIGNA, payment will always be made to the provider even if this
section is not signed. If the provider is contracted with CIGNA, the provider will be paid by CIGNA at the contracted rate. If you have
already paid for services, you should seek reimbursement directly from the provider.
D2.
(City)
B. NAME OF SPOUSE (Last Name, First Name, Middle Initial)
E.
EMPLOYEE’S SIGNATURE
N/A
B. DATE OF BIRTH
EMPLOYED FULL-TIMEF.
C. DATE OF BIRTH
IF YES TO D1. OR D2. AND THE OTHER INSURANCE IS PRIMARY, ENCLOSE A COPY OF THE EXPLANATION OF BENEFITS (EOB) WITH THIS FORM AND THE ITEMIZED BILL(S).
MF
Insured and/or Administered by
Connecticut General Life Insurance Company
CIGNA HealthCare
RETIRED*EMPLOYED
A.
AT THE TIME MEDICAL SERVICE WAS PROVIDED WAS THE PATIENT:
D. SEX
D. DATE OF ACCIDENT OR BEGINNING OF ILLNESS
IS THE PATIENT COVERED UNDER ANOTHER EMPLOYER GROUP HEALTH INSURANCE PLAN
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
IS THE PATIENT COVERED UNDER MEDICARE
NOYES
Spouse
DATE EMPLOYEE’S SIGNATURE
PAYMENT INSTRUCTIONS
The information provided on this form may be disclosed to other persons or entities, including my Plan Sponsor, for the
purpose of processing this claim and performing health plan administration.
I certify that the information supplied is true and correct.
NOYES
YYYYMM DD
( )
C. NAME OF SPOUSE’S EMPLOYER
C. EMPLOYEE’S MAILING ADDRESS (No., Street)
(City)
(State) (Zip Code) ADDRESS OF SPOUSE’S EMPLOYER (No.,Street)
DAYTIME TELEPHONE #
YYYYMM DD
YYYYMM DD
YYYY
(City) (State) (Zip Code)
MM DD
YYYYMM DD
( )
(State) (Zip Code)
YYYYMM DD
D1.
YYYYMM DD
DATE
YYYYMM DD
Not to be used for Pharmacy or Dental claims
I authorize payment to be made directly to the healthcare provider(s) indicated on the enclosed bill(s)
CERTIFICATION
Please refer to reverse side for instructions.
This form can be used for all medical plans.
This form only needs to be completed if the provider is not submitting the claim on your behalf.
Out-of-network claims can be submitted by the provider if the provider is able and willing to file on your behalf.
Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance
or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information
concerning any material fact thereto, commits a fraudulent insurance act which is a crime. For residents in the following states,
please see the last page of this form: Alaska, Arizona, California, Colorado, District of Columbia, Florida, Kentucky, Maryland,
Minnesota, New Jersey, New York, Oregon, Pennsylvania, Tennessee, Texas and Virginia.
Clear Fields
Form Information
Cigna Medical Claim Form
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