Medical Forms

The forms center contains tools that may be necessary for filing certain claims, appealing claims and changing information about your office.
Document Title Document Type Document Size Last Updated
Medical Forms
CMS-1500 (HCFA1500) Online Resource -- 02/03/2015
Coordination of Benefits Verification PDF 287kB 01/12/2023
Health Care Professional Dispute Resolution Request - CA HMO PDF 60KB 02/05/2015
Medical-Network Adequacy Provision Exception Form PDF 320kB 05/17/2023
Out-of-Network Disclosure Form – Referral to a non-participating provider Online Resource -- 03/21/2019
Physician Referral Form Online Resource -- 03/06/2017
Precertification Form Cervical Fusion or Cervical Disc Replacement PDF 292kB 03/01/2022
Precertification Form Lumbar Fusion PDF 300kB 03/01/2022
Prior Authorization Fax Form PDF 171KB 12/29/2021
Request for Health Professional Payment Review PDF 75KB 02/05/2015
Request for Health Professional Payment Review - Member PDF 656KB 02/26/2015
Request-Refuse Interpretation Services – English (all states except CA) PDF 106KB 03/17/2023
Request-Refuse Interpretation Services – English (all states except CA) – Readable PDF PDF 172KB 03/17/2023
Request-Refuse Interpretation Services – Spanish (all states except CA) PDF 215KB 03/17/2023
Submit a Referral to Cigna for Specialty Care PDF 47 KB 02/09/2021
UB-04 Online Resource -- 02/03/2015
Document Title Document Type Document Size Last Updated
State Forms
Arizona Standard Prior Authorization Form PDF 1.26MB 09/14/2023
Arkansas Prior Authorization Exemption Legislation FAQs PDF 143KB 11/23/2023
California – Request-Refuse Interpretation Services – English PDF 405 KB 09/13/2013
California – Request-Refuse Interpretation Services – Spanish PDF 24 KB 09/13/2013
California – Request-Refuse Interpretation Services – Chinese PDF 97 KB 09/13/2013
Florida Medical Prior Authorization Form PDF 314KB 09/14/2023
Indiana Prior Authorization Form PDF 766KB 09/14/2023
Massachusetts Cardiac Imaging Prior Authorization Form PDF 203KB 09/14/2023
Massachusetts CT/CTA/MRI/MRA Prior Authorization Form PDF 190KB 09/14/2023
Massachusetts PET/PET CT Prior Authorization Form PDF 170KB 09/14/2023
Massachusetts Chemotherapy and Supportive Care Prior Authorization Form PDF 6.58MB 02/07/2024
New Mexico Prior Authorization Form PDF 243KB 09/14/2023
Texas Prior Authorization Exemption Legislation FAQs Online Resource 165KB 10/03/2023
Texas Standard Prior Authorization Request Form for Health Care Services PDF 1.15MB 09/14/2023
Vermont Gold Carding Pilot Program PDF 148kB 03/17/2022
Vermont Medical Prior Authorization Form PDF 233kB 01/19/2024
West Virginia Prior Authorization Form PDF 113Kb 09/14/2023
Document Title Document Type Document Size Last Updated
Wellness Forms
Wellness Screening Form PDF 730KB 09/03/2021
Wellness Screening Form (Spanish) PDF 291KB 09/03/2021
Activity-Based Physician-Recommended Alternative and Waiver (Form A) PDF 318KB 09/03/2021
Activity-Based Physician-Recommended Alternative and Waiver (Form A) Spanish PDF 210KB 09/03/2021
Outcomes-Based Physician- Recommended Alternative and Waiver (Form B) PDF 275KB 09/03/2021
Outcomes-Based Physician- Recommended Alternative and Waiver (Form B) Spanish PDF 225KB 09/03/2021