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CIGNA Prior Approval Form

This document is a request for prior approval of medical services from an insurer. It lists medical services that require prior approval from the insurer's medical consultant before treatment begins. It includes items like paramedical treatment, orthopedic appliances, dental work, inpatient care, infertility treatment, and pharmaceutical products. The request is for the listed medical services to be approved for a specific patient and includes a space for a prescribing physician to provide justification and details of the required treatment for review by the insurer's medical consultant.

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214 views1 page

CIGNA Prior Approval Form

This document is a request for prior approval of medical services from an insurer. It lists medical services that require prior approval from the insurer's medical consultant before treatment begins. It includes items like paramedical treatment, orthopedic appliances, dental work, inpatient care, infertility treatment, and pharmaceutical products. The request is for the listed medical services to be approved for a specific patient and includes a space for a prescribing physician to provide justification and details of the required treatment for review by the insurer's medical consultant.

Uploaded by

Dimitar Filevski
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Request for prior approval

The medical services listed below cover those items which are subject to prior approval by the insurers’ medical consultant. In case of
doubt on the reimbursement or the conditions applicable for these or other medical services the insurers’ advice should be sought prior to the
beginning of the treatment.

Staff member Patient


Name Name

First name First name

Cigna pers. ref. no. (UPI no.) Date of birth (d-m-y)

3 5 7 / Relationship Spouse Child

1. Paramedical treatment (prescribed by a doctor)


Alternative medicine (e.g. chiropractic treatment, osteopathy, acupuncture) Sessions

Physiotherapy (from 6 sessions) Sessions

Psychological treatment (from 6 sessions) Sessions

Speech therapy (from 6 sessions) Sessions

Home nurse Days hours per day

Dietician Sessions

Pedicure Sessions

2. Orthopaedic appliances (bandages, corsets, soles, shoes, etc)


Specification

3. Orthodontic treatment for adults / therapeutic prostheses / crowns / bridges


Crowns (3 or more)

Bridges/implants

Orthodontic treatment after age 18

4. Inpatient care in a specialised establishment


Hospice care (terminally ill) Days

Rehabilitation after surgery Days

5. Infertility treatment
Infertility treatment Days

6. Pharmaceutical products (prescribed by a doctor)


Vitamins

Chinese medicine

Infertility treatment

In support of this application, I enclose a sealed envelope for the attention of the medical consultant, containing a detailed,
justificatory report as well as details on the required treatment
dated from the prescribing physician

Date Section reserved for the insurer's medical consultant


In view of a smooth administration of the contract
Signature Authorisation for and/or settlement of the insurance claim, and only for
that purpose, I hereby give my specific and informed
Date consent regarding the processing of the medical data
concerning myself and/or the members of my family
Signature (article 7 of the Belgian law of December 8, 1992
concerning the private life).
5.90.247invc_EN (1114)

Cigna International Health Services BVBA • Plantin en Moretuslei 299 • 2140 Antwerpen • Belgium • RPR Antwerpen • VAT BE 0414 783 183 • FSMA 13799 A-R

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