Use this form to get reimbursed for Medical/Hospital claims that were incurred from out-of-network providers. This form, along with the required claims information, can also be faxed to Cigna at 1-859-410-2422. The fax is to be addressed to the attention of the “Cigna Mailroom”. On average, Cigna will complete all out-of-network claims within 30 days of the receipt of the claims. (In-network providers will bill Cigna directly).
Use this form to submit a claim when you use an out-of-network pharmacy to obtain prescriptions. (if you use a network pharmacy, the pharmacy can submit the claim on your behalf).
Dental Out of Network Claim Form Use this form to get reimbursed for Dental PPO claims that were incurred from out-of-network providers. In-network providers will bill CIGNA Dental directly. (your dentist files claims for covered services under the DHMO).
Davis Vision Out of Network Claim Form Use this form to get reimbursed for Vision claims that were incurred from out-of-network providers. In-network providers will bill Davis Vision directly.
Health Insurance Portability and Accountability Act
Appointment of Personal Representative Form
Use this form to authorize a personal representative to act for you in receiving any information provided to you as a participant/beneficiary of the Plan.
Request That PHI Be Transmitted Confidentially by Alternate Means
Use this form to authorize different address or manner or place where an individual will receive PHI (Protected Health Information).
Use this form to submit a complaint, such as perceiving an employee violating the privacy policies and procedures.
Request for Access to PHI Form
Use this form to request to inspect and copy specified PHI (Protected Health Information).
Request for Restrictions on Use & Disclosure
Use this form to request that use and access to PHI (Protected Health Information) be restricted in a specified manner.
Request for Accounting of Disclosure of PHI
Use this form to request an accounting of the disclosures of PHI (Protected Health Information).
Please mail the completed forms to:
Equity-League Health Trust Fund 165 W 46 St, 14th Floor New York, NY 10036.