Cigna Medicare Advantage Arizona Application Fax Cover Sheet
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1Cigna Medicare Advantage
Arizona Application Fax Cover
Sheet
Effective immediately, all Cigna Medicare applications must
include this fax sheet.
To: Cigna Enrollment and Eligibility Department
From:
Fax: 855.531.9754
Agent Id:
Phone: 800.973.9183 option 2
Date:
Re: New AZ Medicare Advantage Enrollment Application
# of Pages:
Name of Applicant: ______________________________________________________________________
Please check all that apply to this application submission:
☐ New Application
☐ Conversion
☐ Chronic Eligibility Verification Form
☐ Transition of Care
☐ SOA Form
☐ SOA Confirmation #
Comments:
Don’t Forget! Every Application must have your name and agent ID to avoid a
delay in commission payments.
For questions regarding eligibility or enrollments, please contact HAAL (HealthSpring Agent
Assistance Line) at 800.973.9183, Option 2.
CONFIDENTIALITY NOTICE: If you have received this facsimile in error, please immediately notify the sender by telephone at the
number above. The documents accompanying this facsimile transmission contain confidential information. This information is intended
only for the use of the individual(s) or entity named above. Thank you for your compliance.
“Cigna” is a registered service mark and the “Tree of Life” logo is a service mark of Cigna Intellectual Property, Inc., licensed for use by
Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and
not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life
Insurance Company, Cigna Health Management, Inc., Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of
Cigna Health Corporation and Cigna Dental Health, Inc.
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