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Date the form. Forms received without signature will not be processed. Please write clearly. Forms that are not legible may be returned. Physicians (or Licensed Medical Professionals) When documenting biometric results, please include the biometric value and date the specific value was taken. Please sign and date the form. If you have questions about completing this form please call the number on your Cigna ID card. If you are not enrolled in a Cigna medical plan, please call 1-800.

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