Generic fax request form
Providers: you must get Prior Authorization (PA) for services before service is provided. PA is not guarantee of payment.
Payment is subject to coverage, patient eligibility and contractual limitations. Please use appropriate form for Durable
Medical Equipment (DME) and Home Health Care requests.
Date _______ /_______ /_______ Please check request type
¨ Standard request
Note: If the service has already been provided,
please follow retro process and submit claim.
¨Expedited Requests-May take up to 72 hours.
I certify that waiting for a decision under the standard time
frame could place the enrollees life, health, or ability to
regain maximum function in serious jeopardy.
Provider signature required
Patient name Requesting provider
Patient ID # Provider NPI #
Patient birthdate Contact name
Contact phone # Contact fax #
Date of service _____/______/_______ Name of facility/place of service/specialist __________________________________
MA ONLY: Is provider part of a regulated facility? ¨ Yes ¨ No
Diagnosis with ICD 10
¨ Inpatient
¨ Outpatient
Service or procedure, including codes Quantity or number of visits requested
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks
are owned by Cigna Intellectual Property, Inc. 936620 b 03/20 © 2020 Cigna INT_20_85095_C
Please fax this form and supportive clinical to Pre-Cert department below by market:
Market Phone # Fax #
TN, IL, IN, No. MS, No. GA, East AR 800.453.4464 866.287.5834
AL, FL, NC, SC, So. MS, Atlanta 800.962.3016 800.872.8685
TX, AR, OK 832.553.3456 888.205.8658
MA, PA, DE, DC, KC, CO, NJ 888.454.0013 800.931.0145
For a list of services requiring PA, visit or call your states Pre-Cert Department
If you need help finding a PAR facility or provider, please call 800-230-6138 or visit and
use the Provider Search Tool.
<Patient name>
<Requesting provider>
<Patient ID Number>
<Provider NPI #>
<MM / DD / YYYY>
<Contact phone>
<Contact fax>
<Facility/place/specialist name>
click to sign
click to edit