INT_20_88242
924543 Rev. 07/2020
Operating (DBA) name:
MEDICARE ADVANTAGE
FACILITY/ANCILLARY NETWORK INTEREST FORM
Corporate Name :
AL
AR
CO
☐
Hospital:
☐
Acute Inpatient
☐
Long Term Care
☐
Transplant Program:
☐
Kidney
☐
Heart
☐
Pancreas
☐
Liver
☐
Lung
☐
Critical Care Services – Intensive Care Units (ICU)
☐
Cancer Center
☐
Cardiac Catheterization Services
☐
Cardiac Program:
☐
Surgery
☐
Monitoring
☐
Testing
☐
Mammography Center
☐
Outpatient/Ambulatory Surgery Center (ASC)
☐
Rehab Facility:
☐
Inpatient
☐
Outpatient
☐
Diagnostic:
☐
Testing
☐
Radiology
☐
Therapy:
☐
Physical
☐
Occupational
☐
Speech Language
☐
Respiratory
☐
Ambulance/ Transportation Service
☐
Skilled Nursing Facility:
☐
Vent
☐
Onsite Dialysis
Behavioral Health services, please go to
CignaforHCP.com
☐
Endoscopy Center
☐
Federally Qualified Health Center
☐
Radiology
☐
Sleep Clinic
☐
Infusion Therapy Services
☐
Dialysis Center
☐
Durable Medical Equipment
☐
Orthotics
☐
Prosthetics
☐
Home Health Agency
☐
Hearing Aid Provider
☐
Urgent Care Center
☐
Laboratory Services
☐
Other:
This form can be downloaded, printed and sent by email or fax. You may also complete it electronically and return via email. Please note that it can take up to 60 days to receive a response to
your Network Interest Form. If this form is returned without all required questions answered, the form will not be processed.
© 2020 Cigna. Some content may be provided under license.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South
Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health
Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna
Intellectual Property, Inc.
Email: TXMAContracting@Cigna.com
NOTE: Cigna will review your request and send notification to you once a decision has been rendered. Determinations are based on
network need and current availability of services. All providers are subject to Cigna credentialing requirements and applicable state
and federal guidelines.
Submission of Interest Form Does Not Guarantee Acceptance by the Plan
OFFICE CONTACT INFORMATION
(Cigna will use this information for any questions, concerns or responses regarding this form)
(_____)
Date: Name: Email:
(_____)
Phone:
Fax:
Address:
City: State: Zip Code:
FACILITY/ANCILLARY INFORMATION
NPI#: Tax ID#:
Medicare #: Medicaid #:
Are you accredited Yes No
If yes, list the accrediting entity:
Network Participation you seek: Medicare Note: Providers must be enrolled in Medicare in an approved status
(_____)
(_____)
Location
1
SERVICE LOCATIONS
(Only list locations where you actively practice. *If you have more than 2 locations, please attach additional location information)
Address: City: State: Zip Code:
(_____)
Phone: Fax:
Location
2
Address:
City: State: Zip Code:
(_____)
Phone: Fax:
Office Hours:
Counties Serviced:
Office Hours:
Counties Serviced:
County Located:
Medicare Star Rating (if applicable):
County Located:
Medicare Star Rating (if applicable):
SERVICE AREAS COVERED
SCPANJNCMSMOMDKSILGAFLDEDC TN TX
FACILITY/ANCILLARY SPECIFICATIONS
BILLING INFORMATION
(This information should match your W-9)
Address: City: State: Zip Code:
Phone:
Fax:
(_____) (_____)
Tax ID:
