Provider Update Form
Mail To: Network Operations
Cigna Behavioral Health
6625 W 78th Street, Suite 100
Bloomington, MN 55439
Fax Network Operations: 1.860.687.9429
Note: This form is for updating information only. Claims should not be mailed, emailed, or faxed to Network Operations.
IDENTIFYING INFORMATION
License Name :
1
Provider ID:
Type 1 NPI:
Email Address:
1
Enter your name as it appears on your state license.
To update your taxpayer information or claim payment address, please attach an updated W-9 form with your submission.
GENERAL
Preferred Name (For Directory Display Only):
Select Current Status:
License Type :
2
Select Current Status:
American Board of Medical Specialties Certification:
Select Current Status:
Non-English Languages:
Select Current Status:
4
3
Include only one mailing address for administrative correspondence, including authorization letters.
2
If your license information has changed, please include a copy of the updated license with your submission.
4
Use this space to add specialties not appearing on the Specialty Attested or Specialty Verified forms at CignaForHCP.com
HOSPITAL ADMITTING PRIVILEGES
Use this space to add or remove Hospitals at which you have admitting privileges.
Facility Facility Address NPI (Type 2) Action
OFFICE INFORMATION
LOCATION DETAIL:
Select Current Location Detail Status
✔
( if applicable):
Telehealth Only
State:
Home Visits Only
Zip:
Street Address:
City: State: Zip:
Phone Number:
Handicapped Accessible?
Yes
No
Is this place of service also your residence?
Yes
No
Office E-mail (to be displayed on directory) :
5
Web Address:
Qualified Medical Interpreter (QMI) Languages :
Appointment Availability E-Mail:
6
Panel Status:
Other:
Not Accepting Patients
Available only Through a Hospital or Facility
Available by Referral Only
Accepting Existing Patients OnlyAccepting New and Existing Patients
Applicable through (Provide Date):
LOCATION DETAIL:
Select Current Location Detail Status
✔
( if applicable):
Telehealth Only
State:
Home Visits Only
Zip:
Street Address:
City:
State:
Zip:
Phone Number:
Handicapped Accessible?
Yes
No
Is this place of service also your residence?
Yes
No
Office E-mail (to be displayed on directory) :
5
Web Address:
Qualified Medical Interpreter (QMI) Languages :
Appointment Availability E-Mail:
6
Panel Status:
Other:
Not Accepting Patients
Available only Through a Hospital or Facility Available by Referral OnlyAccepting Existing Patients OnlyAccepting New and Existing Patients
Applicable through (Provide Date):
Online Scheduling Available
Online Scheduling Available
5
By providing an Office Email, provider attests that: all Office E-mail addresses are intended for patient communication, are regularly monitored,
and are maintained in a manner consistent with state and federal health privacy laws.
6
Providing QMI Languages serves as attestation that corresponding Qualified Medical Interpreter(s) work at this office.
7
Duration of Accepting Existing Patients Only or Not Accepting Patients status may not exceed 90 days.
All Cigna products and services are provided excluisively by or throuigh operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company,
Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name,
logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
874491 Rev. 01/2021
© 2020 Cigna. Some Content provided under license.
7
7
Admin Mailing Address (Street Address):
3
Select Current Status:Zip:State:
City:
Specialties :
4
Specialties :
Select Current Status:
Select Current Status:
When checked, street address is not required.
Supported only in commercial directories.
When checked, street address is not required.
Supported only in commercial directories.
