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***Not to be used for Pharmacy or Dental claims***

**This form can be used for all medical plans.** CIGNA HealthCare

This form only needs to be completed if the provider is not submitting
the claim on your behalf.

Out-of-network claims can be submitted by the provider if the provider
is able and willing to file on your behalf.

***Please refer to PAGE 2*** for instructions.

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</colgroup>
<tbody>
<tr class="odd">
<td colspan="34"><strong>EMPLOYEE INFORMATION: <em>Employee complete
this section</em></strong></td>
</tr>
<tr class="even">
<td colspan="21" rowspan="2"><p>A. EMPLOYEE’S NAME <em>(Last Name, First
Name, Middle Initial)</em></p>
<p><strong>     </strong></p></td>
<td colspan="13">B. DATE OF BIRTH</td>
</tr>
<tr class="odd">
<td colspan="5"><p>MM</p>
<p>     </p></td>
<td colspan="5"><p>DD</p>
<p>     </p></td>
<td colspan="3"><p>YYYY</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="10"><p>C. EMPLOYEE’S MAILING ADDRESS <em>(No.,
Street)</em></p>
<p>     </p></td>
<td colspan="5"><p>(City)</p>
<p>     </p></td>
<td colspan="2"><p>(State)</p>
<p>     </p></td>
<td colspan="4"><p>(Zip Code)</p>
<p>     </p></td>
<td colspan="13"><p>DAYTIME TELEPHONE</p>
<p>(       )     </p></td>
</tr>
<tr class="odd">
<td colspan="7"><p>IS THIS A CHANGE OF ADDRESS?</p>
<p><em>(Note: address must also be changed with Employer)</em></p>
<p> Yes No</p></td>
<td colspan="11"><p>D. CIGNA ID NUMBER OR EMPLOYEE SOCIAL SECURITY
NUMBER</p>
<p><em>(on the front of your CIGNA ID card)      </em></p></td>
<td colspan="16"><p>E. ACCOUNT NO. (on the front of your CIGNA ID
card)</p>
<p><strong>3172368</strong></p></td>
</tr>
<tr class="even">
<td colspan="15" rowspan="2"><p>F. EMPLOYER NAME</p>
<p><strong>Sandia National Laboratories</strong></p></td>
<td colspan="6" rowspan="2"><p>G. EMPLOYER STATUS</p>
<p> EMPLOYED RETIRED*</p>
<p> COBRA* DISABLED*</p></td>
<td colspan="13">*EFFECTIVE DATE</td>
</tr>
<tr class="odd">
<td colspan="5"><p>MM</p>
<p>     </p></td>
<td colspan="5"><p>DD</p>
<p>     </p></td>
<td colspan="3"><p>YYYY</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="34"><strong>PATIENT INFORMATION: <em>Complete only if
patient is other than employee</em></strong></td>
</tr>
<tr class="odd">
<td colspan="15" rowspan="2"><p>A. PATIENT’S NAME <em>(Last Name, First
Name, Middle Initial)</em></p>
<p>     </p></td>
<td colspan="6" rowspan="2"><p>B. RELATIONSHIP TO EMPLOYEE</p>
<p>Spouse Child Other</p></td>
<td colspan="11">B. DATE OF BIRTH</td>
<td colspan="2" rowspan="2"><p>D. SEX</p>
<p>M F</p></td>
</tr>
<tr class="even">
<td colspan="4"><p>MM</p>
<p>     </p></td>
<td colspan="3"><p>DD</p>
<p>     </p></td>
<td colspan="4"><p>YYYY</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="15"><p>E. PATIENT’S ADDRESS – IF DIFFERENT THAN EMPLOYEE
ADDRESS <em>(No., Street)</em></p>
<p>     </p></td>
<td colspan="8"><p><em>(City)</em></p>
<p><em>     </em></p></td>
<td colspan="7"><p><em>(State)</em></p>
<p><em>     </em></p></td>
<td colspan="4"><p><em>(Zip Code)</em></p>
<p><em>     </em></p></td>
</tr>
<tr class="even">
<td colspan="34">F. AT THE TIME MEDICAL SERVICE WAS PROVIDED WAS THE
PAITENT: EMPLOYEED FULL-TIME STUDENT FULL-TIME N/A</td>
</tr>
<tr class="odd">
<td colspan="34"><p><strong>ACCIDENT/OCCUPATIONAL CLAIM
INFORMATION:</strong></p>
<p><em><strong>Complete only if claim is a result of an accident or
occupational (work related) illness/injury</strong></em></p></td>
</tr>
<tr class="even">
<td colspan="3"><ol type="A">
<li><p>ACCIDENT OR ILLNESS</p></li>
</ol>
<blockquote>
<p>DUE TO EMPLOYMENT?</p>
<p> YES NO</p>
</blockquote></td>
<td colspan="9"><p>B. INJURY DUE TO<br />
AUTO ACCIDENT?</p>
<p> YES NO</p></td>
<td colspan="22"><p>C. DESCRIPTION OF HOW ACCIDENT OR WORK RELATED
ILLNESS/INJURY OCCURRED</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="8">D. DATE OF ACCIDENT OR BEGINNING OF ILLNESS</td>
<td colspan="26" rowspan="2"><p>E. ARE YOU OR YOUR DEPENDENTS FILING A
CLAIM OR LAWSUIT AGAINST A THIRD PARTY INCLUDING AN INSURANCE<br />
COMPANY IN ORDER TO RECOVER THE COST OF EXPENSES INCURRED AS A RESULT OF
THIS ACCIDENT OR ILLNESS?</p>
<p> YES NO If yes, Name of Third Party:      </p></td>
</tr>
<tr class="even">
<td><p>DD</p>
<p>     </p></td>
<td colspan="3"><p>MM</p>
<p>     </p></td>
<td colspan="4"><p>YYYY</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="34"><p><strong>FAMILY/OTHER COVERAGE
INFORMATION:</strong></p>
<p><em><strong>Complete only if claim is for a dependent and/or other
coverage is in effect</strong></em></p></td>
</tr>
<tr class="even">
<td colspan="13">A. SPOUSE EMPLOYED? IF NO, HAS SPOUSE BEEN
EMPLOYED<br />
YES NO DURING LAST 12 MONTHS?</td>
<td colspan="9" rowspan="2"><p>B. NAME OF SPOUSE <em>(Last Name, First
Name, Middle Initial)</em></p>
<p>     </p></td>
<td colspan="12">SPOUSE’S DATE OF BIRTH</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="11">     </td>
<td colspan="5"><p>MM</p>
<p>    </p></td>
<td colspan="6"><p>DD</p>
<p>     </p></td>
<td><p>YYYY</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="5"><p>C. NAME OF SPOUSE’S EMPLOYER</p>
<p>     </p></td>
<td colspan="11"><p>ADDRESS OF SPOUSE’S EMPLOYER <em>(No.,
Street)</em></p>
<p>     </p></td>
<td colspan="4"><p><em>(City)</em></p>
<p>     </p></td>
<td colspan="4"><p><em>(State)</em></p>
<p>     </p></td>
<td colspan="5"><p><em>(Zip Code</em></p>
<p>     <em>)</em></p></td>
<td colspan="5"><p>TELEPHONE #</p>
<p>(       )     </p></td>
</tr>
<tr class="odd">
<td colspan="34">D1. IS THE PATIENT COVERED UNDER ANOTHER EMPLOYER GROUP
HEALTH INSURANCE PLAN? YES NO If yes, provide:</td>
</tr>
<tr class="even">
<td colspan="6">NAME OF HEALTH INSURANCE COMPANY</td>
<td colspan="8">EFFECTIVE DATE OF COVERAGE</td>
<td colspan="5">POLICY NUMBER</td>
<td colspan="15">TYPE OF PLAN (HMO OR PPO) IF KNOWN</td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="3"><p>MM</p>
<p>     </p></td>
<td colspan="2"><p>DD</p>
<p>     </p></td>
<td colspan="3"><p>YYYY</p>
<p>     </p></td>
<td colspan="5">     </td>
<td colspan="15">     </td>
</tr>
<tr class="even">
<td colspan="34"><p>D2. IS THE PATIENT COVERED UNDER MEDICARE  YES 
NO</p>
<p><em><strong>IF YES TO D1. OR D2. AND THE OTHER INSURANCE IS PRIMARY,
ENCLOSE A COPY OF THE EXPLANATION OF BENEFITS (EOB) WITH THIS FORM AND
THE ITEMIZED BILL(S).</strong></em></p></td>
</tr>
<tr class="odd">
<td colspan="34"><strong>CERTIFICATION</strong></td>
</tr>
<tr class="even">
<td colspan="34"><p><strong>Any person who knowingly and with intent to
defraud any insurance company or other person: (1) files an application
for insurance or statement of claim containing any materially false
information; or (2) conceals for the purpose of misleading, information
concerning any material fact thereto, commits a fraudulent insurance act
which is a crime. For residents in the following states, please see the
last page of this form: Alaska, Arizona, California, Colorado, District
of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New
York, Oregon, Pennsylvania, Tennessee, Texas and Virginia.</strong></p>
<p><strong>I certify that the information supplied is true and
correct.</strong></p></td>
</tr>
<tr class="odd">
<td colspan="22" rowspan="2"><p><strong>EMPLOYEE SIGNATURE</strong></p>
<p><strong>X</strong></p></td>
<td colspan="12">DATE</td>
</tr>
<tr class="even">
<td colspan="5"><p>MM</p>
<p>     </p></td>
<td colspan="6"><p>DD</p>
<p>     </p></td>
<td><p>YYYY</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="34"><strong>PAYMENT INSTRUCTIONS</strong></td>
</tr>
<tr class="even">
<td colspan="34"><strong>I authorize payment to be made directly to the
healthcare provider(s) indicated on the enclosed bill(s)</strong></td>
</tr>
<tr class="odd">
<td colspan="22" rowspan="2"><p><strong>EMPLOYEE SIGNATURE</strong></p>
<p><strong>X</strong></p></td>
<td colspan="12">DATE</td>
</tr>
<tr class="even">
<td colspan="5"><p>MM</p>
<p>     </p></td>
<td colspan="6"><p>DD</p>
<p>     </p></td>
<td><p>YYYY</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="34"><em><strong>Please be aware that if the provider of
service holds a contract with CIGNA, payment will always be made to the
provider even if this section is not signed. If the provider is
contracted with CIGNA, the provider will be paid by CIGNA at the
contracted rate. If you have already paid for services, you should seek
reimbursement directly from the provider.</strong></em></td>
</tr>
<tr class="even">
<td colspan="34"><strong>NOTE: The information provided on this form may
be disclosed to other persons or entities, including my Plan Sponsor,
for the<br />
purpose of processing this claim and performing health plan
administration.</strong></td>
</tr>
</tbody>
</table>

**INSTRUCTIONS FOR FILING A CLAIM**

**IMPORTANT**

**1. This form can be used for all medical plans.** This form only needs
to be completed if the provider is not submitting the claim on your
behalf. Out-of-network claims can be submitted by the provider if the
provider is able and willing to file on your behalf.

**2.** If you received this claim form electronically, you can fill in
the fields by clicking to the right of the first field (Employee's Name)
and typing in the information. Remember to click on the Clear Fields
button on the top of page 1 after printing out the completed claim form.

**3.** If you are completing this form by hand, use a new printed form
rather than a photocopy to ensure the form can be scanned into our
system. Also, be sure to print clearly and use black ink when you
complete the form.

**4.** Claim must be postmarked within one year of your date of service
for claims to be considered payable.

**5.** Use a separate claim form for each provider and each member of
the family. A new form can be obtained from
[[www.cigna.com]{.underline}](http://www.cigna.com/) under HealthCare,
Important Forms or by calling Member Services using the toll-free number
on your CIGNA ID card.

**6.** Your claim cannot be processed without your ID Number (Employee
Section, Block D). Please reference the front of your CIGNA ID card to
find this number. Your ID may be the employee's Social Security Number.

**7.** You must submit an itemized bill for your claim to be processed.
Receipts, balance due statements and cancelled checks are not acceptable
replacements for the itemized bill.

**8** ITEMIZED BILLS MUST INCLUDE:

Employee Name Provider Name Date of Service

Patient Name Provider Address Diagnosis

Type of Service Provider Tax ID Number Charge for Service

**9.** We suggest you make a copy of your bill(s) and your completed
claim form for your records. If you are submitting one claim, please do
not paper clip or staple your claim form and bill(s). If you are
submitting multiple claims in one envelope, please paper clip the
appropriate claim form and itemized bill(s) together.

**10.** Please be aware that payment will be sent to the provider,
unless the provider is non-contracted with CIGNA and you submit a
receipt that shows you paid in full (a zero balance) with your itemized
bill and this claim form. CIGNA reserves the right to request additional
documentation, such as medical records prior to processing your claim.

**11.** If the patient has coverage through another health insurance
carrier which is considered primary (CIGNA as secondary), you must
submit the Explanation of Benefits (EOB) from the insurance carrier for
this service along with this completed form and itemized bill.

**EXPLANATION OF BENEFITS**

You will receive an Explanation of Benefits (EOB) after your claim is
processed explaining the charges applied to your deductible and any
charges you owe to the provider. Please keep your EOBs for later
reference.

**MAILING INSTRUCTIONS**

*If you are submitting one claim, please do not paper clip or staple
your claim form and bill(s). If you are submitting multiple claims in
one envelope, please paper clip the appropriate claim form and itemized
bill(s) together.*

If you are enrolled in an HMO, POS, or Open Access plan (excluding Open
Access Plus), please mail in-network and out-of-network Mental Health or
Substance Abuse claims to:

CIGNA Behavioral Health, Inc.

Attn: Claims Service Dept.

P.O. Box 46270

Eden Prairie, MN 55344-6270

Send your ***completed claim form*** and itemized bill(s) to the **CIGNA
address listed on your identification card.**

**If you have additional questions, please contact Member Services using
the toll-free number on your ID card.**

807873 04/07 ©2007 CIGNA

**Caution:** Any person who, knowingly and with intent to defraud any
insurance company or other person: (1) files an application for
insurance or statement of claim containing any materially false
information; or (2) conceals for the purpose of misleading, information
concerning any material fact thereto, commits a fraudulent insurance
act.

**IMPORTANT CLAIM NOTICE**

**Alaska Residents:** A person who knowingly and with intent to injure,
defraud or deceive an insurance company or files a claim containing
false, incomplete or misleading information may be prosecuted under
state law.

**Arizona Residents:** For your protection, Arizona law requires the
following statement to appear on/with this form. Any person who
knowingly presents a false or fraudulent claim for payment of loss is
subject to criminal and civil penalties.

**California Residents:** For your protection, California law requires
the following to appear on/with this form. Any person who knowingly
presents a false or fraudulent claim for the payment of a loss is guilty
of a crime and may be subject to fines and confinement in state prison.

**Colorado Residents:** It is unlawful to knowingly provide false,
incomplete or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of insurance, and
civil damages. Any insurance company or agent of an insurance company
who knowingly provides false, incomplete or misleading facts or
information to a policyholder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to
the Colorado Division of Insurance within the Department of Regulatory
Agencies.

**District of Columbia Residents:** WARNING: It is a crime to provide
false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided
by the applicant.

**Florida Residents:** Any person who knowingly and with intent to
injure, defraud or deceive any insurer files a statement of claim or an
application containing any false, incomplete or misleading information
is guilty of a felony of the third degree.

**Kentucky Residents:** Any person who knowingly and with intent to
defraud any insurance company or other person files a statement of claim
containing any materially false information or conceals, for the purpose
of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime.

**Maryland Residents:** Any person who, knowingly and with intent to
defraud any insurance company or other person: (1) files an application
for insurance or statement of claim containing any materially false
information; or (2) conceals for the purpose of misleading, information
concerning any fact material thereto, may be committing a fraudulent
insurance act.

**Minnesota Residents:** A person who files a claim with intent to
defraud or helps commit a fraud against an insurer is guilty of a crime.

**New Jersey Residents:** Any person who knowingly files a statement of
claim containing any false or misleading information is subject to
criminal and civil penalties.

**New York Residents:** Any person who knowingly and with intent to
defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false
information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance
act, which is a crime and shall also be subject to a civil penalty not
to exceed \$5000 and the stated value of the claim for each such
violation.

**Oregon Residents:** Any person who knowingly and with intent to
defraud any insurance company or other person: (1) files an application
for insurance or statement of claim containing any materially false
information; or, (2) conceals for the purpose of misleading, information
concerning any material fact, may have committed a fraudulent insurance
act.

**Pennsylvania Residents:** Any person who, knowingly and with intent to
defraud any insurance company or other person, files an application for
insurance or statement of claim containing any materially false
information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance
act, which is a crime and subjects such person to criminal and civil
penalties.

**Tennessee Residents:** It is a crime to knowingly provide false,
incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines
and denial of insurance benefits.

**Texas Residents:** Any person who knowingly presents a false or
fraudulent claim for the payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.

**Virginia Residents:** Any person who, with the intent to defraud or
knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement
may have violated state law.