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  • Cigna Dental Oral Health Integration Program Registration Form

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Se mail the completed form to: Cigna Dental P.O. Box 188044 Chattanooga, TN 37422-8044 A. PRIMARY CUSTOMER INFORMATION Primary Customer Name: (Last, First, Middle Initial) SSN or Cigna Customer ID: Address: (Street) (City) Telephone Number: (State) Employer Name: E-Mail Address: (Zip Code) Employer Group Number: B. PATIENT INFORMATION Patient Name: (Last, First, Middle Initial) Patient Date of Birth: Patient's Relationship to the Primary Customer: Self Spouse Dependent Other C. M.

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Basic restorative care: This usually includes things like fillings, extractions, and non-routine X-rays. Major restorative care: This includes things like bridges, crowns, and dentures. Orthodontic treatment: This includes things like space maintainers, braces, and other devices used to align your teeth.

Maximum Allowable Charge (MAC): The most Cigna will pay a dentist for a covered service or procedure for out-of-network dental care that is based on a basic Cigna DPPO Advantage fee schedule within a specified area.

Dependent children are eligible up to age 26. A newborn child or newly adopted child, born or adopted to an enrolled subscriber, may be added to the subscriber's plan within 31 days of the birth or adoption.

Cancellation: Customers may cancel at any time by calling 1.877. 521.0244 or by sending correspondence to Cigna Dental, 8100 S.W. 10th Street, Suite 2000, Plantation, FL 33324.

By choosing a DPPO Advantage dentist, you receive a higher network benefit coverage than you would with a DPPO dentist. This may result in lower out-of-pocket expenses. Pay less for covered services because network dentists have agreed to offer services at lower negotiated rates.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232