9 Select payment method Cheque Bank wire transfer
*by providing this information, payment will be transferred more eciently by the receiving bank
10 Should payment be sent to your bank account, please complete the following:
Bank account no. Bank name
Sort Code Name of account holder
Swift Code* IBAN*
Bank branch address:
11 I authorise the release of any medical information necessary to process this claim. To the best of my knowledge all the details
given are true.
I warrant and represent that I have each covered person’s consent to disclose the personal information, including the sensitive personal
information (e.g. medical information) contained in this form to you. I confirm that each covered person is aware of their duty to take
reasonable care to answer questions accurately, honestly, completely and to the best of their knowledge.
(Please note that if you are declaring the above on another person’s behalf, it is your obligation to keep evidence of the consent you
are providing hereto of your covered family members’ actual declarations and consents.)
Signature of insured person (or Legal Representative):
Date
DENTAL CLAIM FORM
PATIENT’S DETAILS
To be completed by the beneficiary or his/her legal representative
1 Patient name
2 Policy ID 3 Patient’s date of birth
4 Full mailing address of patient
5 State nature of illness
Email address Tel no Fax no
6 Do you have any other health or travel insurance policy for which you may receive full or partial
reimbursement for these expenses?
Yes No
If you have answered yes in section 6, please give details below:
Full name Policy number
Address of insurance company
PAYMENT DETAILS
To be completed by the beneficiary or his/her legal representative
7 List of expenses for which reimbursement is claimed and amount 8 State to whom you wish settlement paid and currency
Treatment Date Amount Payment to Currency
HOW WE USE YOUR INFORMATION
We will collect, use, store, and disclose your personal information, including sensitive information (in particular, information relating to your
medical history and any medical treatment you may have or have had), in accordance with relevant data protection legislation. We collect
and will use your personal information, including sensitive information, for the purpose of carrying out our obligations under this plan.
We may share your information, including sensitive information, with other Cigna companies and authorised healthcare providers, where
necessary to carry out our obligations under this plan. This statement also applies to personal information of any beneficiaries detailed on
this application form. You have the right to request a copy of your personal information held by us, and beneficiaries under your policy have
the right to request a copy of personal information we hold about them. We may charge a fee to provide this information.
THIS SECTION TO BE COMPLETED BY THE DENTIST
PREVENTATIVE TREATMENT
CODE TREATMENT
NO OF
UNITS
DATE OF
TREATMENT
CHARGE
TO PATIENT
EXAMINATIONS
A01
Normal
A11
Extensive
A21
Full case assessment
X-RAYS
B01
Bitewing
B02
Intra oral
B03
O.P.G.
SCALING AND POLISHING
E01
One visit
D01
Fissure sealants
D11
Topical fluoride application
M0U
Occlusal splint
MINOR TREATMENT
FILLINGS
G01
Amalgam - one surface
G02
Amalgam - two surfaces
G03
Amalgam - three+ surfaces
G21
Composite - one surface
G22
Composite - two surfaces
G31
Additional charge use of pin
ROOT CANAL TREATMENT
H01
Upper and lower anterior (1 root)
H02
Upper premolar (2 roots)
H03
Lower premolar (1 root)
H04
Molars (3+ roots)
EXTRACTIONS
L01
Single
L02
Per additional tooth
N11
Post-operative care
MAJOR TREATMENT
CODE TREATMENT
NO OF
UNITS
DATE OF
TREATMENT
CHARGE
TO PATIENT
PERIDONTAL TREATMENT (NON-SURGICAL)
E21
Prolonged (curettage/root planing)
F51
Splinting
PERIDONTAL TREATMENT (SURGICAL)
F01
Gingivectomy
F11
Mucoperio, flap bone surgery
DENTURES – METAL/ACRYLIC
R63
Additional tooth
R61
Addition of clasp
K71
Denture repair
CROWNS/BRIDGES
J01
Veneers (per tooth)
K32
Adhesive bridges
K41
Conventional bridgework
K12
Standard post and core
K11
Gold post and core
K07
Bonded precious crown
K05
Bonded non-precious crown
K08
Full cast crown
K06
Porcelain crown
INLAYS
K02
Precious
K01
Non-precious
K03
Porcelain
I confirm that the treatment has been/will be carried out and I hereby
declare that all treatment as stated is being submitted for approval/has
been completed.
Dentist’s signature:
Date:
Dentist’s stamp:
TOTAL
Please return your fully completed form along with the original receipt/invoices to:
FRAUD NOTICE: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for
insurance or statement of claim containing deliberately false information, commits a fraudulent insurance act, which is a crime.
We will not deal with any claims which we believe to be fraudulent. Committing fraud may result in your policy being terminated, or we will
investigate any claims which we believe to be fraudulent.
Your relevant Cigna contracting entity from those listed below will be detailed in your Policy Rules and Certificate of Insurance.
a) Cigna Life Insurance Company of Europe S.A-N.V.; or
b) Cigna Global Insurance Company Limited; or
c) Cigna Worldwide General Insurance Company Limited; or
d) Cigna Europe Insurance Company S.A-N.V.
Treatment incurred outside the USA send to:
Cigna Global Health Options
1 Knowe Road
Greenock
PA15 4RJ
Scotland
Tel: +44 (0) 1475 788182
Fax: +44 (0) 1475 492113
Email: cignaglobal_customer.care@cigna.com
Cigna Dental Claim form 05/2018
Treatment incurred inside the USA send to:
Cigna International
PO Box 15964
Wilmington, Delaware 19850
United States of America
Tel: +44 (0) 1475 788182
Fax:
855 358 6457
Email: cignaglobal_customer.care@cigna.com
