Provider Registration

Full name of the provider (as it appears on the invoice)*

Web Url

Address 1 *

Address 2

Address 3

City*

Postal Code*

Country*

Billing/Payment Address (only if different from above) No Yes

Billing Address 1*

Billing Address 2

Billing Address 3

City*

Postal Code*

Country*

P.O. Box No Yes

P.O. Box*

City*

Postal Code*

Country*

Number of beds in

Private Accommodation

Semi-private Accommodation

Ward

Member of Hospital Group No Yes

Name of Group*

General

Name

Tel

Fax

Email

Admission Desk /Guarantee of Payment

Name

Tel

Fax

Email

Agreements

Name

Tel

Fax

Email

Billing/Finance

Name

Tel

Fax

Email

Payment Details

Account Holder Name

Account No. (IBAN No. for European Countries)

Bank Account Currency

Full Bank name and Address

BIC/SWIFT code

Bank ID (if applicable)

Price Lists

Price Lists (please send us your price lists)
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Complementary Information

What is the legal entity type of the hospital?* Public Private Other

If Other, please specify*

International Patient Desk No Yes

No. of international patients admitted last year

Languages spoken by the staff of the hospital*

Status doctors Independent Payroll

Which are the credentials of the doctors who work at the hospital and what is the credentialing process?

Medical liability insurance No Yes

If Yes, please specify*

Accreditations: No Yes

If Yes, please specify*

Is the hospital considered as a centre of excellence for specific diagnoses or treatments? No Yes

If Yes, please specify*

Does the hospital have agreements with international insurance companies? No Yes

If Yes, please specify*

Does the hospital have agreements with international companies or organisations? No Yes

If Yes, please specify*

Does the hospital have agreements with other hospitals on a national/international basis? No Yes

If Yes, please specify*

Is the hospital member of a national/international hospital federation? No Yes

If Yes, please specify*

List of specialties

Please add your specialties Add

Application Form to join the Cigna International network of preferred providers

Application Form to join the Cigna International network of preferred providers

General Information

Physical Address

Contacts

General

Admission Desk /Guarantee of Payment

Agreements

Billing/Finance

Payment Details

Price Lists

Complementary Information

List of specialties

Application Form to join the Cigna International network of preferred providers

Your application is complete