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
	Antifungal coverage request (PDF 163k)
	Cox II coverage request (PDF 158k)
	DACON coverage request (PDF 154k)
	Erectile Dysfunction coverage request (PDF 173k)
	Medication Prior Authorization (PDF 154k)
	Proton Pump Inhibitor coverage request (PDF 40k)
	Weight Management medications request (PDF 157k)

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