Provider Update Instructions

Please update as much information as necessary. The receipt of accurate, up-to-date information is essential to ensuring the success of referral and administrative processes at Cigna.

For any information you are unable to submit on the Provider Information Update Form, please contact your Provider Relations Field Office.

Once you have completed the necessary form, click on the submit button. We appreciate your time. Thank you.

*Indicates required field

Provider Information

*Last/Business Name:

First Name:

*Phone Number:

*State Where Provider Is Located:

Degree:

License:

Provider's SSN:

MAILING ADDRESS: ONLY ONE PER PROVIDER

(All authorizations and administrative correspondence will be sent to this address.)

*Street/PO Box:

Suite:

*City:

*State:

*ZIP:

*E-mail Address:

Office Location to be Terminated

Office Location to be Terminated

Street:

Street:

Suite:

Suite:

Office Location #1

Billing for Location #1

Replacement Additional NA

Same as Mailing Location #1 Different

Street/PO Box:

Street/PO Box:

Suite:

Suite:

City:

City:

State:

State:

ZIP:

ZIP:

Telephone:

Telephone:

Cell Phone:

Tax ID#:

Fax:

If Tax ID# change, W-9 must be faxed to Network Ops @ (860) 687-7257.

Pager:

Tax ID Registered Name:  

NOTE: Name assigned to Tax ID by IRS.

Office Location #2

Billing for Location #2

Replacement Additional NA

Same as Mailing Location #2 Different

Street/PO Box:

Street/PO Box:

Suite:

Suite:

City:

City:

State:

State:

ZIP:

ZIP:

Telephone:

Telephone:

Cell Phone:

Tax ID#:

Fax:

If Tax ID# change, W-9 must be faxed to Network Ops @ (860) 687-7257.

Pager:

Tax ID Registered Name:  

NOTE: Name assigned to Tax ID by IRS.

Comments: