Get Cigna Health Care Reimbursement Request Form 2021-2025

This guide provides you with a clear and comprehensive approach to completing the Cigna Health Care Reimbursement Request Form online. By following the steps outlined below, you can ensure that your reimbursement request is processed swiftly and accurately.

Follow the steps to successfully complete your reimbursement request.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing your employee information. Enter your Cigna ID number or Social Security number, last name, first name, middle initial, and date of birth. Make sure to complete the mailing address, city, state, and zip code fields. Each of these fields marked with an asterisk (*) is required.
3. Next, fill in your employer's name and account number(s). Refer to your Cigna medical card if you are unsure about your account number.
4. Proceed to the patient information section. Enter the patient's name, date of birth, and the start date of the service. It is crucial to provide the first date of service if the services were provided over multiple days.
5. Clearly state the amount you are requesting for reimbursement, ensuring you indicate that you have attached the necessary receipt or Explanation of Benefits suitable for the amount claimed.
6. Specify the type of service or purchase and provide the corresponding procedure code or description of the service. Additionally, include the name of the health care professional, facility, or store where the service was obtained.
7. Before submission, verify that you sign your declaration affirming that the expenses are eligible healthcare expenses and that you have adhered to all IRS regulations. Failure to sign this section may result in your form being returned.
8. Once you have completed and signed the form, you can then fax it to the designated numbers provided or mail it to the specified Cigna address. If you have questions, consult the provided contact information for assistance.

Start completing your Cigna Health Care Reimbursement Request Form online today for seamless processing.