Get Cigna Disability Management Solutions Medical Request Form 2020-2025

Completing the Cigna Disability Management Solutions Medical Request Form online can seem daunting, but with clear guidance, you can navigate through it effectively. This form is essential for evaluating a patient’s disability claim and requires specific details to ensure a thorough review.

Follow the steps to fill out the medical request form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the claimant's name in the designated field. Ensure that the name matches the documentation you are submitting.
3. Next, provide the date of birth for the claimant. This is crucial for verifying the identity and age of the patient.
4. Identify the primary diagnosis responsible for the patient's impairment. Use clear and specific language to indicate how this condition affects their ability to return to work.
5. Enter the ICD-9 code corresponding to the primary diagnosis. This code is essential for medical record-keeping and claim processing.
6. Document the date of injury or illness in the appropriate field to provide context for the claim.
7. Indicate whether the condition is work-related by selecting 'Yes' or 'No'. This information assists in determining the nature of the claim.
8. If applicable, describe any specific additional medical or non-medical factors that impact the patient's return to work. This can include environmental conditions or personal circumstances.
9. Provide the date when you first treated the patient for the current impairment episode, which helps establish the timeline of treatment.
10. If you have treated the patient for this impairment in the past, answer 'Yes' or 'No' and list the date of the prior treatment episode if applicable.
11. Enter the date of the last office visit. This helps track ongoing treatment and evaluation.
12. Note the date of the patient's next office visit if scheduled, which provides insight into ongoing care.
13. Indicate any components of the treatment plan for the impairment episode, including physical therapy, imaging studies, or referrals by checking the relevant boxes and providing supporting documentation.
14. List all current medications related to the impairment, including dosages and frequency, to inform the review process.
15. Record any specific restrictions placed on the patient regarding work activities as well as activities of daily living at home.
16. Answer the question about whether the patient could return to work with accommodations. Provide details if they cannot return to work.
17. Estimate when the patient can return to work, both with and without restrictions, based on your professional experience.
18. Print the physician's name clearly, followed by their degree and specialty in the designated fields.
19. Fill in the address, including street, city, state, and zip code, along with the telephone number to ensure contact is possible.
20. Complete the Federal Tax ID number as required for the submission.
21. Finally, sign and date the form to validate the information presented.
22. Once all fields are accurately filled, proceed to save your changes, download the form, print it, or share it as needed for further processing.

Begin filling out the Cigna Disability Management Solutions Medical Request Form online today to support your patient's claim.