1) Use this form for out-of-network providers. In-network providers will bill CIGNA Dental directly.

2) The participant must fill out the section labeled "Part I-To Be Completed by Employee." The Dentist must fill out section labeled "Part II - To Be Completed By the Attending Dentist." If the Dentist prefers to give you an itemized bill that you can attach to the form, this is acceptable but be sure it contains all of the required information.

If the Dentist has not been paid, and you wish CIGNA Dental to pay the benefits directly to the Dentist, please sign the "Authorization to Pay Benefits to Dentist."

3) Please mail the completed claim form to:

CIGNA HealthCare Service Center
PO Box 188036
Chattanooga, TN 37422-8036

4) CIGNA Dental will then process your claim for payment. If additional information is required in order to process the claim, CIGNA Dental will contact either you and/or the Dentist.