Get Cigna Provider Enrollment Form

Completing the Cigna Provider Enrollment Form online is a necessary step for providers seeking enrollment. This guide provides clear instructions, tailored for users of all experience levels, to help navigate each section of the form effectively.

Follow the steps to fill out the Cigna Provider Enrollment Form online.

1. Click 'Get Form' button to obtain the form and open it in the online editor.
2. In Section A, provide information about your employer. Fill in the employer's name, address, and the effective date of any add/change/cancellation. Specify the type of change you are making, such as new enrollment, reinstatement, or change.
3. In Section B, enter your personal information. This includes your name, date of birth, home and work phone numbers, social security number, email address, and your employee identification number. If you are enrolling dependents, list their names and social security numbers as requested.
4. For Section C, choose your preferred medical plan options. Select the appropriate Cigna plan and specify your primary care physician or healthcare center if applicable.
5. In Section D, indicate if you want any flexible spending account options. If choosing an option, ensure you complete any required additional forms.
6. Section E requires you to select dental coverage options and confirm if you are declining coverage. Make sure to check off the selections that apply to you.
7. In Section F, disclose if you or any dependents have other health insurance. Provide necessary details, including the effective date of any existing coverage.
8. Section H and I cover life and accidental death and dismemberment (AD&D) options. If applicable, complete these sections, including designating beneficiaries for life insurance.
9. Carefully review all entered information to ensure accuracy. Once verified, you can save changes, download the form, print it out, or share it as needed for submission.

Complete your Cigna Provider Enrollment Form online today to ensure a smooth enrollment process.