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Claim Form
Name of Member Name of Patient Members No. Name of Employer/Group Scheme
Download your next claim form from your member portal www.cigna.co.uk/members or CIGNA website www.cigna.co.uk/yoursolutions/memberdownloads.
Date of Birth Date of Birth
1. Patients Details
To be completed by patient. Please complete in BLOCK CAPITALS. Address Postcode: Telephone No. Email Address: Please let us know how you would like your claim paid (please tick): Name of Account Holder(s) Branch Sort Code Cheque Bank Account Relationship to Member:
2. 3.
Data Protection Act 1998 - We need your explicit approval to process your data as some of the information contained in the claim may be classified as sensitive data under the Act. Please confirm your agreement by signing below. Signature of Patient: ................................................................................................................................................................................................................................ (or Parent/Guardian if under 18) Date:...........................................................................................................
CIGNA HealthCare
NHS TREATMENT
Date of Treatment Band 1 Band 2 Band 3 Band 4 BD1DN BD2DN BD3DN BD4DN
CODE
Charge to Patient
MAJOR TREATMENT
TREATMENT
NO OF TOOTH DATE OF CHARGE TO UNITS NUMBER TREATMENT PATIENT
PREVENTATIVE TREATMENT
CODE
TREATMENT
EXAMINATIONS
E21 F51
Q31 Q32
Partial or Full Upper OR Lower Partial or Full Upper AND Lower DENTURES - METAL
Q43 Q41
E01
MINOR TREATMENT
CODE
J01
NO OF TOOTH DATE OF CHARGE TO UNITS NUMBER TREATMENT PATIENT
Veneers (per tooth) Adhesive Bridges Conventional Bridgework Standard Post & Core Gold Post & Core Bonded Precious Crown Bonded Non Precious Crown Full Cast Crown Full Porcelain Crown INLAYS
TREATMENT
FILLINGS
Amalgam-One Surface Amalgam-Two+Surfaces Amalgam-Three+Surfaces Composite Anterior-One Surface Composite Anterior-Two+Surfaces Composite Posterior-One Surface Composite Posterior-Two+Surfaces Additional charge use of pin ROOT CANAL TREATMENT
Upper & Lower Anterior (1 root) Upper Premolar (2 roots) Lower Premolar (1 root) Molars (3 + roots) EXTRACTIONS
TREATMENT
Accident Emergency
AEG OAE
Total I that the treatment has been/will be carried out under the N.H.S./privately and I hereby declare that all treatment and charges as stated are being submitted for approval/have been completed. Signature (qualified staff member) : Date :
W11 P42
Dressings Incising an Abcess Open Root Canal for Drainage Recementing Crowns/Bridges Abnormal Haemorrhaging
Dentists Stamp