591692c Rev. 09/2012
Medical Claim Form
COBRA***
NOTE: Cigna may disclose the information on this form to other persons and entities, including your employer (if your coverage is through
your employer). We may do this to process the claim or administer the health plan.
EFFECTIVE DATE OF COVERAGE
PRIMARY CUSTOMER INFORMATION: Primary Customer complete this section
If yes, provide: NAME OF HEALTH INSURANCE COMPANY
X
POLICY NUMBER TYPE OF PLAN (HMO OR PPO) IF KNOWN
NOYES
NO If yes, Name of Third Party: _____________________________________________________________________YES
NOYES
DISABLED***
STUDENT FULL-TIME
*** EFFECTIVE DATE
IMPORTANT: When the health care professional holds a Cigna contract, Cigna will always pay the health care professional directly, even if
this section is left unsigned. We pay the health care professional at the contracted rate. If you already paid the health care professional for
the services you received, you should ask your health care professional to pay you back.
N/AEMPLOYED FULL-TIME
F. AT THE TIME MEDICAL SERVICE WAS PROVIDED WAS THE PATIENT:
If you answered Yes to D1 and/or D2 above, and the other insurance company is primary, then please send us this form and (a) a copy of the explanation of benefits
(EOB) and (b) the itemized bill(s) for this claim.
Insured and/or Administered by
Connecticut General Life Insurance Company
Cigna Health and Life Insurance Company
Cigna HealthCare*
RETIRED***EMPLOYED
NOYES
NOYES
YYYYMM DD
YYYYMM DD
YYYYMM DD
( )
DATE
YYYYMM DD
I authorize Cigna to make payment directly to the health care professional listed on the enclosed bills.
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 Mexico, New
York, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas and Virginia.
I certify that the information supplied is true and correct.
B. DATE OF BIRTHA2. GENDER
YYYYMM DD
M F
OtherChild M
F
Spouse
YYYYMM DD
NOYESNOYES
This form can be used with all medical plans. It's not intended for Dental or Pharmacy claims.**
**Please note:
You only need to fill out this form if your health care professional isn't filing the claim for you.
Even if not part of the Cigna network (out-of-network), your health care professional still can file the claim for you.
We've added instructions on the back of this form to make it easy for you to complete.
You can find Dental and Pharmacy claim forms on mycigna.com. Go to: Review My Coverage>Dental or Pharmacy>Related Links.
*"Cigna HealthCare" refers to the various HMO subsidiaries of Cigna Health Corporation. If you are enrolled in a Cigna HMO plan, complete details can be found in your
plan documents or Evidence of Coverage.
"Cigna" is a registered service mark, and the "Tree of Life" logo is a service mark, of Cigna Intellectual Property, Inc. licensed for use by Cigna Corporation and its operating
subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include
Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Health Management, Inc., and HMO subsidiaries of Cigna Health
Corporation.
A1. PRIMARY CUSTOMER’S NAME (Last Name)
(First Name) (M.I.)
C. PRIMARY CUSTOMER’S MAILING ADDRESS (No., Street)
(City) (State) (ZIP Code)
DAYTIME TELEPHONE #
IS THIS A CHANGE OF ADDRESS?
(Note: address must also be changed with Employer, if applicable)
D. CIGNA ID NUMBER OR PRIMARY CUSTOMER SOCIAL SECURITY NUMBER
(on the front of your Cigna ID card)
E. ACCOUNT NO. (on the front of your Cigna ID card)
F. EMPLOYER NAME
G. PRIMARY CUSTOMER STATUS
PATIENT INFORMATION: Complete this section only if the patient is not the primary customer
D. GENDER
C. DATE OF BIRTHB. RELATIONSHIP TO PRIMARY CUSTOMER
(M.I.)(First Name)A. PATIENT’S NAME (Last Name)
E. PATIENT’S ADDRESS - IF DIFFERENT THAN PRIMARY CUSTOMER ADDRESS (No., Street)
(City) (ZIP Code) (State)
A. ACCIDENT OR ILLNESS
DUE TO EMPLOYMENT?
B. INJURY DUE TO
AUTO ACCIDENT?
C. DESCRIPTION OF HOW ACCIDENT OR WORK-RELATED ILLNESS/INJURY OCCURRED
D. DATE OF ACCIDENT OR BEGINNING OF ILLNESS 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?
ACCIDENT/OCCUPATIONAL CLAIM INFORMATION:
Complete this section only if you are filing the claim because of an accident or occupational (work-related) illness or injury
FAMILY/OTHER COVERAGE INFORMATION:
Complete only if claim is for a dependent and/or other coverage is in effect
A. SPOUSE EMPLOYED? IF NO, HAS SPOUSE BEEN EMPLOYED
DURING LAST 12 MONTHS?
B. NAME OF SPOUSE (Last Name) (M.I.)(First Name)
SPOUSE'S DATE OF BIRTH
YYYYDDMM
C. NAME OF SPOUSE'S EMPLOYER
ADDRESS OF SPOUSE’S EMPLOYER (No., Street)
(ZIP Code) (State)
(City)
TELEPHONE #
( )
D1. IS THE PATIENT COVERED UNDER ANOTHER HEALTH INSURANCE PLAN?
D2. IS THE PATIENT COVERED UNDER MEDICARE?
NO
YES
CERTIFICATION
PRIMARY CUSTOMER'S SIGNATURE
PAYMENT INSTRUCTIONS
PRIMARY CUSTOMER'S SIGNATURE
YYYYDD
DATE
MM
X
