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Starbridge ChoicesStarbridge Choices - An innovative limited-benefit medical plan for the part-time and hourly workforce.

Starbridge Choices>Member Resources>Important Forms

Claim Identification Form

1. Complete the Claim Identification Form

Note: claim forms may be photocopied

2. Attach original bills (bills must be originals, not photocopies).

      3. Attach copy of "Certificate of Creditable Coverage" from your prior
      insurer, if applicable.

      4. Mail (Facsimile documents can not be accepted) to:

      Connecticut General Life Insurance Company
      Starbridge Choices
      P.O. Box 55270
      Phoenix, AZ 85078-5270
      Toll Free: (800) 308-5948
      Phone: (602) 484-9633

      IMPORTANT: Please submit your claim within 90 days of the date of service.

      Dental Claim Form
      Complete and include this form when submitting a dental claim to Starbridge Choices.

Dependent Verification Form

Complete and include this form when submitting a claim to Starbridge Choices for a dependent.

Confidential Communications


Auth PHI Form


HIPAA Accounting


HIPAA Statement of Disagreement


HIPAA Amendment


HIPAA Personal Rep. Request


HIPAA Restriction of Use


HIPAA Change Revoke


HIPAA Request for Access


Beneficiary Designation Notification Form

Completing and returning this form will allow Starbridge Choices to pay a chosen beneficiary upon the insured person's death.

      Adobe Acrobat Reader Download Click here to download Adobe Acrobat Reader.

CIGNA HealthCare’s Claims Department is staffed with Customer Service Representatives ready to provide assistance from Monday through Friday 5 a.m. to 6 p.m., MST at 1-800-308-5948. Spanish speaking representatives are available.

Privacy Statements | Disclaimer Phone: 1-800-258-9260

CIGNA HealthCare
“CIGNA” and “CIGNA HealthCare” refer to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these operating subsidiaries and not by CIGNA Corporation. These operating subsidiaries include Connecticut General Life Insurance Company, Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc.