Careallies prior authorization form: Fill out & sign online

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Click ‘Get Form’ to open the Cigna IOP request form in our platform's editor.
Begin by entering today's date and the Cigna U# at the top of the form. This information is crucial for processing your request.
Fill in the client's name, date of birth, and policyholder’s SSN. Ensure accuracy as this data is essential for identification.
Provide the previous authorization number, facility name, and tax ID. These details help streamline communication with Cigna.
Indicate the level of care requested (IOP) and any extensions needed. Specify the requested start date of authorization.
Complete sections regarding client living arrangements, number of sessions requested, DSM-5 diagnoses, and current medications.
Address questions about relapse prevention plans and treatment goals thoroughly to ensure a comprehensive review.
Once all fields are filled out accurately, save your changes and submit the form via fax to Cigna Behavioral Health at 860-687-7329.

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