Forms

Medical Claim Form for Group

• Medical Claim Form – English (PDF)
• Medical Claim Form – En Español (Spanish) (PDF)

Medicare – Medical – MHN Claim Form & Foreign Claim Questionnaire

• MHN Claim Form & Foreign Claim Questionnaire – English (PDF)

Group Member GRIEVANCE FORM

• GRIEVANCE FORM – English (PDF)
• GRIEVANCE FORM – Chinese Mandarin 中文 (PDF)
• GRIEVANCE FORM – En Español (Spanish) (PDF)

Department of Managed Health Care (DMHC)

• Right to Submit Request for Review of Cancellation, Rescission, or Nonrenewal of Your Plan Contract, Enrollment, or Subscription – English (PDF)
• Request for Review of Cancellation, Rescission, or Nonrenewal of Plan Contract – English (PDF)

Is there a Cigna Provider Nomination process/form?

No, there is no form. Members can contact Health Net Member Services at the number on their Member ID card to request that a provider be added to the Cigna Healthcare PPO Network.

Authorization For Disclosure of PHI

• Authorization For Disclosure of PHI – English (PDF)
• Authorization For Disclosure of PHI – En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI – Chinese Mandarin 中文 (PDF)
• Authorization For Disclosure of PHI – Korean 한국어 (PDF)

Glossary of Health Coverage and Medical Terms

• Glossary of Health Coverage and Medical Terms – English (PDF)
• Glossary of Health Coverage and Medical Terms – En Español (Spanish) (PDF)
• Glossary of Health Coverage and Medical Terms – Chinese Mandarin 中文 (PDF)
• Glossary of Health Coverage and Medical Terms – Navajo Diné bizaad (PDF)
• Glossary of Health Coverage and Medical Terms – Korean 한국어 (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.