924602 11/2020
Medicare Advantage
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.
Facility/Patient Information
Market
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:
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance
Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
© 2021 Cigna.
Facility NPI:
Patient Name: Facility Name:
Patient ID:
Patient DOB:
(Month/Day/Year)
Diagnosis with ICD 10:
Contact Phone Contact Fax
Contact Name:
(Month/Day/Year)
Date of Admission:
Date of Discharge
(if applicable):
(Month/Day/Year)
Select Admission Type:
Inpatient Observation
Phone Number
800-453-4464
800-962-3016
888-454-0013
832-553-3456
Fax Number
866-234-7230
866-234-7230
866-234-7230
888-205-9577
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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.
INT_21_95091_C
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