#1
March 31st, 2017, 05:08 PM
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Cigna MBA Claim Form
Can you provide me the Medical Benefits Abroad (MBA) Claim Application Form of Cigna Health and Life Insurance Company?
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#2
April 1st, 2017, 10:06 AM
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Re: Cigna MBA Claim Form
The Medical Benefits Abroad (MBA) Claim Application Form of Cigna Health and Life Insurance Company is as follows: Cigna MBA Claim Form Few Things to be mentioned in the Form Section A – Employee/Patient and Travel Information Date(s) of service, earliest date if multiple (MM/DD/YYYY) Country where services were rendered Diagnosis/Reason for treatment Travel Dates: (required for claim submission) Departure from home country on/Return to home country on Employer Name/Policy/Group Number Employee’s Name (Last)/Patient’s Name (Last) Employee’s Name (First):/Patient’s Name (First) Employee’s Date of birth (MM/DD/YYYY)/Patient’s Date of Birth (MM/DD/YYYY) Employee’s Mailing Address City: State: Postal/Zip Code |