INT_20_84981_C933189 04/2020
(_____)
(_____)
(_____)
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Location
1
MEDICARE ADVANTAGE
MEDICAL PRACTITIONER NETWORK INTEREST FORM
OFFICE CONTACT INFORMATION
(Cigna will use this information for any questions, concerns or responses regarding this form)
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
Date: Name: Email:
(_____)
Phone:
Fax:
Address:
City: State: Zip Code:
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PRACTITIONER INFORMATION
First:
Last: MI: Degree:
NPI #: Medicare #: Medicaid #: CAOH #:
Desired Role:
Behavioral Health providers, please go to
CignaforHCP.com
Primary Care Specialty Care
In-Office Laboratory (must have CLIA certification) Part B Drugs
Radiology (accredited and enrolled with Medicare) DME (accredited and enrolled with Medicare as DME
Provider)
Therapy Services -PT/OT/Speech Pathology
(Appropriately licensed and enrolled with Medicare)
Nurse Practitioners and/or Physician Assistants
Preferred Specialty 1:
Preferred Specialty 2:
Are you board certified in this specialty?
Are you board certified in this specialty?
Yes No
Yes No
If your specialty is (Other) please list specialty:
If NP or PA, name of supervising physician: NPI of supervising physician:
Do you have admitting privileges Yes No If Yes, list hospital(s):
If No, list alternate admitting arrangements:
Are you in Residency?
Yes No
Applications will not be accepted prior to 30 days of residency completion
Network Participation you seek: Medicare
HMO PPO Group Products
Note: Providers must be enrolled in Medicare in an approved status
What lab(s) do you use:
PRACTICE 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:
GROUP INFORMATION
Are you joining an existing group that is currently on par with Cigna Medicare?
Yes No Solo Provider
BILLING INFORMATION
(This information should match your W-9)
Group Name: Group NPI:
Address:
City: State: Zip Code:
Phone:
Fax:
(_____)
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.
NPI: Tax ID:
Email: Provider_Intake_Form_MA/PA@healthspring.com
