Member Claim Form
Insured and/or Administered by
Connecticut General Life Insurance Company
Not to be used for Pharmacy or Dental claims
CIGNA HealthCare
This form can be used for all medical plans.
This form only needs to be completed if the provider is not submitting the claim on your behalf.
Out-of-network claims can be submitted by the provider if the provider is able and willing to file on your behalf.
Please refer to reverse side for instructions.
EMPLOYEE INFORMATION: Employee complete this section
A. EMPLOYEE’S NAME (Last Name, First Name, Middle Initial)
B. DATE OF BIRTH
MM
DD
YYYY
C. EMPLOYEE’S MAILING ADDRESS (No., Street)
(City)
(State)
(Zip Code)
DAYTIME TELEPHONE #
(
)
IS THIS A CHANGE OF ADDRESS?
D. CIGNA ID NUMBER OR EMPLOYEE SOCIAL SECURITY NUMBER
E. ACCOUNT NO. (on the front of your CIGNA ID card)
(Note: address must also be changed with Employer)
(on the front of your CIGNA ID card)
3209088
YES
NO
*
F.
EMPLOYER NAME
G. EMPLOYEE STATUS
EFFECTIVE DATE
EMPLOYED
RETIRED*
MM
DD
YYYY
Equity-League Health Trust Fund
DISABLED*
COBRA*
PATIENT INFORMATION: Complete only if patient is other than employee
A. PATIENT’S NAME (Last Name, First Name, Middle Initial)
B. RELATIONSHIP TO EMPLOYEE
C. DATE OF BIRTH
D. SEX
MM
DD
YYYY
Spouse
Child
Other
M
F
(City)
(State)
(Zip Code)
E. PATIENT’S ADDRESS - IF DIFFERENT THAN EMPLOYEE ADDRESS (No., Street)
F.
AT THE TIME MEDICAL SERVICE WAS PROVIDED WAS THE PATIENT:
EMPLOYED FULL-TIME
STUDENT FULL-TIME
N/A
ACCIDENT/OCCUPATIONAL CLAIM INFORMATION:
Complete only if claim is a result of an accident or occupational (work related) illness/injury
A. ACCIDENT OR ILLNESS
B. INJURY DUE TO
C. DESCRIPTION OF HOW ACCIDENT OR WORK RELATED ILLNESS/INJURY OCCURRED
DUE TO EMPLOYMENT?
AUTO ACCIDENT?
YES
NO
YES
NO
D. DATE OF ACCIDENT OR BEGINNING OF ILLNESS
E.
ARE YOU OR YOUR DEPENDENTS FILING A CLAIM OR LAWSUIT AGAINST A THIRD PARTY INCLUDING AN INSURANCE COMPANY
IN ORDER TO RECOVER THE COST OF EXPENSES INCURRED AS A RESULT OF THIS ACCIDENT OR ILLNESS?
MM
DD
YYYY
YES
NO If yes, Name of Third Party:
FAMILY/OTHER COVERAGE INFORMATION:
Complete only if claim is for a dependent and/or other coverage is in effect
A.
SPOUSE EMPLOYED?
IF NO, HAS SPOUSE BEEN EMPLOYED
B. NAME OF SPOUSE (Last Name, First Name, Middle Initial)
SPOUSE’S DATE OF BIRTH
DURING LAST 12 MONTHS?
MM
DD
YYYY
YES
NO
YES
NO
C. NAME OF SPOUSE’S EMPLOYER
ADDRESS OF SPOUSE’S EMPLOYER (No., Street)
(City)
(State)
(Zip Code)
TELEPHONE #
(
)
YES
NO
If yes, provide:
D1.
IS THE PATIENT COVERED UNDER ANOTHER EMPLOYER GROUP HEALTH INSURANCE PLAN?
NAME OF HEALTH INSURANCE COMPANY
EFFECTIVE DATE OF COVERAGE
POLICY NUMBER
TYPE OF PLAN (HMO OR PPO) IF KNOWN
MM
DD
YYYY
YES
NO
D2.
IS THE PATIENT COVERED UNDER MEDICARE?
IF YES TO D1. OR D2. AND THE OTHER INSURANCE IS PRIMARY, ENCLOSE A COPY OF THE EXPLANATION OF BENEFITS (EOB) WITH THIS FORM AND THE ITEMIZED BILL(S).
CERTIFICATION
Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or
statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning
any material fact thereto, commits a fraudulent insurance act which is a crime. For residents in the following states, please see the
last page of this form: Alaska, Arizona, California, Colorado, District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey,
New York, Oregon, Pennsylvania, Tennessee, Texas and Virginia.
I certify that the information supplied is true and correct.
EMPLOYEE’S SIGNATURE
DATE
MM
DD
YYYY
X
PAYMENT INSTRUCTIONS
I authorize payment to be made directly to the healthcare provider(s) indicated on the enclosed bill(s)
EMPLOYEE’S SIGNATURE
DATE
MM
DD
YYYY
X
Please be aware that if the provider of service holds a contract with CIGNA, payment will always be made to the provider even if this
section is not signed. If the provider is contracted with CIGNA, the provider will be paid by CIGNA at the contracted rate. If you have
already paid for services, you should seek reimbursement directly from the provider.
NOTE:
The information provided on this form may be disclosed to other persons or entities, including my Plan Sponsor, for the
purpose of processing this claim and performing health plan administration.
591692a Rev. 10/2008