New Cigna Out-of-Network Disclosure Form

November 01, 2014

Cigna is disseminating a new Out-of-Network Disclosure Form this past September with an effective date of December 10, 2014. The new Cigna form is attached below. While the new form is very similar to the old one it is replacing, there are some significant differences.

On December 10, 2014, patients who elect to use their Cigna out-of-network benefits must execute the new form before each referral. After both the provider and the patient have signed the form, a copy of the completed form should be given to the patient with the original included in the patient’s medical file.