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Fundamental Care>Member Resources>Important Forms

      Medical Claims Form

      Most providers bill Fundametal Care directly. If your provider does not bill insurance, here is the information we need to consider your claim. Please take the form to your doctor's office and he/she can help you complete it.

      1. Complete the Claim Identification Form

      Note: claim forms may be photocopied

      2. Attach original bills (bills must be originals, not photocopies).

          3. Attach copy of "Certificate of Creditable Coverage" from your prior
          insurer, if applicable.

          4. Mail (Facsimile documents can not be accepted) to:

          IMPORTANT!

          If you are submitting a claim with a Date of Service before 03/01/2007 please use the following address:

          CIGNA HealthCare
          P.O. Box 30870
          Phoenix, AZ 85046

          If the Date of Service is after 03/01/2007, SEE THE BACK OF YOUR INSURANCE ID CARD FOR CLAIMS SUBMITION ADDRESS. Thank you.

          IMPORTANT: Please submit your claim within 90 days of the date of service.

      Dependent Verification Form

      Complete and include this form when submitting a claim to Fundamental Care for a dependent.

      Confidential Communications


      Auth PHI Form


      HIPAA Accounting


      HIPAA Statement of Disagreement


      HIPAA Amendment


      HIPAA Personal Rep. Request


      HIPAA Restriction of Use


      HIPAA Change Revoke


      HIPAA Request for Access


      Dental Claim Form

      Complete and include this form when submitting a dental claim to Fundamental Care.

      Adobe Acrobat Reader Download Click here to download Adobe Acrobat Reader.

CIGNA HealthCare’s Claims Department is staffed with Customer Service Representatives ready to provide assistance from Monday through Friday 5 a.m. to 6 p.m., MST at 1-800-308-5948. Spanish speaking representatives are available.

Privacy Statements | Disclaimer Phone: 1-800-258-9260

CIGNA HealthCare
“CIGNA” and “CIGNA HealthCare” refer to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these operating subsidiaries and not by CIGNA Corporation. These operating subsidiaries include Connecticut General Life Insurance Company, Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc.