Inpatient/Observation Admission Hospital Request Form
This form is to be used for notification of admission for inpatient and observation hospitalizations. This form is not for prior-authorization of planned
surgical procedures (please refer to Generic fax request form for surgical requests).
This form should be used for notification of admission of emergency admissions, and notice of admit for surgery which has already been authorized.
TN, IL, IN, No MS, GA, East AR
AL, FL, NC, SC So. MS, Atlanta
MA, PA DE, DC, KC, CO NJ
TX, AR, OK
Reminder: Please fax this form and supportive clinical to Inpatient Utilization Management department below by market:
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Patient Name: Facility Name:
Diagnosis with ICD 10:
Contact Phone Contact Fax
Date of Admission:
Date of Discharge
Select Admission Type:
For a list of services requiring PA, visit MedicareProviders.Cigna.com or call your state’s Pre-Cert Department
If you need help finding a PAR facility or provider, please call 800-230-6138 or visit MedicareProviders.Cigna.com and use the
Provider Search Tool.