Privacy Forms

The forms* listed below are for submitting requests mentioned in the "CIGNA HealthCare Notice of Privacy Practices," "Notice of Privacy Practices--CIGNA Community Choice (Medicaid Program)," and "Notice of Privacy Practices--CIGNA HealthCare for Seniors."

If you need to submit a request, select the appropriate link to print a form.

• Request to Access Health Care Information (PDF)
  (PDF)
  (PDF)
• Request to Amend Private Health Information (PDF)
  (PDF)
  (PDF)
• Request for Accounting (PDF)
  (PDF)
  (PDF)
• Request for Restriction of Use (PDF)
  (PDF)
  (PDF)
• Request for Confidential Communications (PDF)
  (PDF)
  (PDF)
• Request for Personal Representative (PDF)
  (PDF)
  (PDF)
• Statement of Disagreement - Amendment Request (PDF)
  (PDF)
  (PDF)
• Change/Revoke Request (PDF)
  (PDF)
  (PDF)
• Authorization for Disclosure of Private Health Information (PDF)
  (PDF)
  (PDF)

Please note: CIGNA HealthCare will not disclose confidential information without your authorization unless it is necessary to provide your health benefits, administer your benefit plan, support CIGNA HealthCare programs or services, or as otherwise required or permitted by law. We will not, for example, give your confidential information to a credit agency, a telemarketer or a prospective employer. We will not sell, rent or license the confidential information you provide to us including any information you provide within our public Web sites unless you authorize it. Our Privacy Notice that we have sent to all CIGNA HealthCare members describes more fully how we use your information. You may also read a copy of the Privacy Notice on this Web site.