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
	Angiotensin Receptor Blockers (ARB) (PDF 29k)
	Antifungal Coverage form (PDF 53k)
	Compounds (PDF 32k)
	DACON Coverage (PDF 153k)
	Erectile Dysfunction Coverage (PDF 38k)
	Insulin Pens (PDF 29k)
	Mandatory Mail Order Exception Form (PDF 28k)
	Narcotic Medications (PDF 34k)
	Pharmacy Claim Form (PDF 63k)
	Medication Prior Authorization (PDF 154k)
	Medicare Pharmacy Claim Form (PDF 197k)
	Tel-Drug Profile (PDF 154k)
	Selzentry (PDF 29k)
	Singulair (PDF 29k)
	Tamiflu/Relenza (PDF 32k)
	Tykerb (PDF 28k)
	Weight Management Medications (PDF 28k)

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

Specialty (Injectable) Drugs: