Get Cigna 583522k 2017-2025

Filling out the Cigna 583522k prescription drug claim form online is an important process for requesting reimbursement for covered expenses. This guide will provide step-by-step instructions to ensure that you complete each section accurately.

Follow the steps to successfully fill out the Cigna 583522k form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate the reason for reimbursement by checking at least one box in the 'Reason for Reimbursement' section, choosing from options like 'Emergency', 'Non-Participating Pharmacy', or others as applicable.
3. Complete the 'Participant/Patient Information' section by filling in the participant's name, employer, Cigna ID number, account number, patient's name, birth date, relationship to participant, and sex. Ensure all information is correct to avoid delays.
4. Sign and date the Certification Statement to confirm that the information provided is accurate and that the patient has received the medication. This is a crucial step to validate your claim.
5. Fill in the 'Prescription Information' section, which requires details of each prescription for which reimbursement is being requested, including medication names and costs.
6. If applicable, provide details for any multi-ingredient compound prescriptions in the provided section, ensuring to include necessary information such as NDC numbers and quantities.
7. After completing all sections of the form, save your changes. You may then download, print, or share the completed form as needed.
8. Ensure you mail the claim form along with all required receipts within 12 months of the prescription fill date to the address provided at the bottom of the form.

Start filing your Cigna prescription drug claim online today to ensure timely reimbursement.