Get Cigna Dental Oral Health Integration Program Registration Form

This guide provides step-by-step instructions on how to effectively complete the Cigna Dental Oral Health Integration Program Registration Form online. By following these detailed guidelines, users will find it straightforward to provide the necessary information for successful registration.

Follow the steps to complete the registration form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, enter your primary customer information including your full name (last, first, and middle initial), social security number or Cigna customer ID, address (street, city, state, and zip code), telephone number, employer name, email address, and employer group number.
3. In Section B, provide the patient information by entering the patient's full name (last, first, and middle initial), their date of birth, and their relationship to the primary customer (options are self, spouse, dependent, or other).
4. In Section C, confirm your medical information by checking the conditions that apply to you, which may include cardiovascular disease, diabetes, chronic kidney disease, and others. Select eligible procedures related to your medical condition by referencing the provided list.
5. In Section D, indicate your preferences for receiving additional information related to the program, such as tobacco cessation or stress impact on oral health. Choose the method of delivery (email or mail) for this information.
6. In Section E, certify your medical condition by checking the applicable boxes and providing your telephone number, medical physician's name, medical carrier, and date. Ensure to include your signature in the designated area to confirm the provided information is accurate.
7. Finally, review all entries for accuracy, then save changes, download, print, or share the completed form as needed.

Take the next step and complete the Cigna Dental Oral Health Integration Program Registration Form online now!