Get Cigna Dental Oral Health Integration Program Reimbursement Form

Filling out the Cigna Dental Oral Health Integration Program Reimbursement Form accurately is essential for obtaining reimbursement for dental services covered under your plan. This guide will provide you with detailed, step-by-step instructions for completing the form online to ensure a smooth submission process.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the Cigna Dental Oral Health Integration Program Reimbursement Form and open it in the designated editor.
2. Begin by completing Section A, which contains the insured or subscriber information. Fill in your full name, address, phone number, email address, and employer name. Make sure to provide the Social Security Number or Cigna Customer ID, along with the employer group number.
3. Proceed to Section B to provide information about other coverage. Indicate your relationship to the policyholder and include the date of birth of the policyholder/subscriber.
4. In Section C, enter the patient's information. This includes the patient's full name and date of birth.
5. Complete Section D by providing the dentist's information, including name, phone number, and address.
6. Fill out Section E with the claim information. Include the date(s) of dental service and the amount paid to the dentist. Check the appropriate procedure(s) for which you are requesting reimbursement.
7. If applicable, indicate your interest in additional perks in Section F. You may request information about tobacco cessation, stress management, or discounts on dental products.
8. In Section G, you will certify your eligibility for additional dental coverage. Review the criteria provided and check the appropriate boxes. Sign and date the form as required.
9. Finally, review all entered information for accuracy. Once confirmed, save your changes, and you may have the option to download, print, or share the completed form as needed.

Complete your Cigna Dental Oral Health Integration Program Reimbursement Form online today for efficient processing.