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© 2020 Cigna INT_20_85170_C
Cigna 360 Comprehensive Assessment and Stipend Payment Verification Letter for 2020.
To ensure your participation and payments for 2020, Cigna 360 Comprehensive Assessments, and meeting attendance stipends, please take a
moment to verify your Tax Identification Number (TIN) for both 360 Comprehensive Assessment payments and stipends for the 2020
Please check all that apply:
For Cigna 360 Comprehensive Assessment payments:
☐ I choose to verify the following TIN for the 2020 Cigna 360 Comprehensive Assessment payments program. TIN#____________
☐ I elect not to participate in the 2020 Cigna 360 Comprehensive Assessment program and understand an outside vendor will be assigned to
perform the 2020, Cigna 360 Comprehensive Assessment on my Cigna Medicare Advantage panel.
For Cigna meeting stipends:
☐ I choose to verify the following TIN#_____________________> for meeting stipends.
☐ I elect to use the following TIN# _________________________ for meeting stipends.
If the TIN number is the same for 360 Comprehensive Assessment and stipend payments please provide one, current W9 for this TIN. If
two different TINs are being utilized, please provide a current W9 for the 360 Comprehensive Assessment payments and a current W9 for
stipend payments. Please be sure to indicate, on each W9, the address the TIN is associated with the IRS. Return all applicable W9’s
along with this signed letter.
Please check the appropriate boxes, sign this letter and return to your Cigna Medicare Advantage Network Operations representative, with
appropriate W9’s and Practice Worksheet forms, to confirm your participation for the 2020 Cigna 360 Comprehensive Assessment and stipend
Failure to return this form or incorrect W9’s or forms will result in the suspension of payment of 360 Comprehensive Assessment and stipends until this letter and appropriate W9’s are
returned to Cigna Medicare Advantage. Your assistance in this verification process will prevent any delays in receiving your payments and stipend payments. If you have any questions,
please contact your Network Operations Representative or Administrator.
Cigna Medicare Advantage of Arizona
Please verify the above TIN(s) is/are correct or has been corrected.
I would like Cigna Medicare Advantage of Arizona to 2020 360 Comprehensive Assessment and stipend payments to this/these TIN(s).
Please print and fax this signed form to 860-771-4368.