Cost Estimate Form

1. A fully completed form at least 5 days before planned out-patient surgeries or inpatient
admission facilitates faster processing. Pre-certification is not necessary for emergency
treatment or outpatient services.
2. Write clearly in black ink and block capitaLs.
3. Return this form prior to care to: authorization@cigna.com
Fax Asia and Pacific + 603 2178 1499
Fax Europe, Africa and Middle East +32 3 217 66 20
Patient Fax North and South America +1 305 908 9091

Cigna reference n° 0 1 7
Plan sponsor (employer,...) A D B
Family name and first name

Date of birth Gender

D M Y M F

Health care provider (alternatively attach the necessary information to this form.)
Cigna provider ID (if available)
Name
Address (Including zip code, city and country)

Contact person

Telephone Fax
Email

Medical information
Diagnosis or reason for admission or code (ICD10, DRG, etc.)

Type of treatment or surgery

Name of the treating physician and/or surgeon

Medical report on the illness/treatment included? Yes No

Expected costs
Hospitalisation with overnight stay? Yes No
Admission date
D M Y Expected discharge date D M Y

Option A
Doctors’ fees with relevant breakdown Currency
Surgeon(s) Anaesthetist(s) Conservative treatment:
treating doctors
Assistant(s) Other

Other medical expenses Currency Other (+specify)

Medication Xrays

Laboratory Implantable
materials
Room type Suite Private Semi-private Ward Cost per day Currency
Room coverage can vary per member depending on medical plan.

Option B (Should only be given if invoice will be billed as package price)

Package rate Currency

Signature
5.90.784invc (1118)

Signature of the plan member and date

D M Y Signature/stamp of the hospital/doctor
I accept the terms and conditions. I certify that the above information is to the best of my knowledge and belief correct and true. The issuance of false claims, the
provisions of misleading information or the withholding of information related thereto is an offence punishable by Law. I hereby confirm that I have read and fully
understood Cigna’s Data Protection Notice (https://www.cignahealthbenefits.com/en/privacy). If I provide Cigna with personal information relating to others, I will make
them aware of Cigna’s Data Protection Notice.
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