Health Care Professional Forms

	Medical Forms

	Explanation of Direct Deposit Activity Report (PDF 82k)
	UB-04 (PDF 15k)
	CMS-1500 (HCFA1500) (PDF 179k)
	Request for Provider Payment Appeal (Texas) – Instructions & Form (PDF 155k)
	Request for Provider Payment Appeal (all others) – Instructions & Form (PDF 160k)
	Provider Dispute Resolution Request (California HMO) – Instructions & Form (PDF 160k)
	Direct Deposit Authorization Form (PDF 160k)

	Dental Forms
	Add a Dentist (online form)
	Dental Claim (PDF 1.4Mb)
	DHMO Uniform Referral for Maryland (PDF 42k)

	Pharmacy Forms
	Amevive coverage request (PDF 46k)
	Antifungal coverage request (PDF 163k)
	ARB coverage request (PDF 52k)
	Lovenox, Fragmin, Arixtra, Innohep coverage request (PDF 51k)
	DACON coverage request (PDF 154k)
	Erectile Dysfunction coverage request (PDF 173k)
	Increlex, iPlex coverage request (PDF 51k)
	IVIG coverage request (PDF 671k)
	Medication Prior Authorization (PDF 154k)
	Proton Pump Inhibitor coverage request (PDF 40k)
	Remicade coverage request (PDF 47k)
	Weight Management medications request (PDF 157k)
	Multiple Sclerosis form (PDF 37k)

	Additional Forms available on cignaforhcp.com (log in required)