CIGNA Medicare Select Plus Rx (HMO) Privacy Forms (Arizona Only)

Please Note: Forms marked with an asterisk ( * ) below may NOT be used if you are in a group-sponsored plan. If you are in a group plan, please call the phone number on your CIGNA ID card or contact your plan administrator if you have questions.

Accounting Form

Use when you want an itemized list of each time we have disclosed your protected health information

Print form and send to:

Privacy Office
CIGNA
PO Box 188014
Chattanooga, TN 37422

Disagreement Statement Form

Use when you want to formally disagree with our denial of your request to amend your protected health information that we maintain.

Print form and send to:

Privacy Office
CIGNA
PO Box 188014
Chattanooga, TN 37422

Change/Revoke Form

Use when you want to change or revoke a previously-approved Request for Restriction, Confidential Communication, Personal Representative, Authorization or Statement of Disagreement.

Print form and send to:

Privacy Office
CIGNA
PO Box 188014
Chattanooga, TN 37422

Restriction of Use Form

Use when you want to request a restriction on the use and disclosure of your protected health information.

Print form and send to:

Privacy Office
CIGNA
PO Box 188014
Chattanooga, TN 37422

Authorization for Disclosure Form

Use when you want to authorize the disclosure of specific protected health information to a specific person or entity.

Print form and send to:

Privacy Office
CIGNA
PO Box 188014
Chattanooga, TN 37422

Amend PHI Form

Use when you want to request an amendment to the protected health information that we maintain.

Print form and send to:

Privacy Office
CIGNA
PO Box 188014
Chattanooga, TN 37422

Confidential Communication Form

Use when you want to have communications containing protected health information sent to a different address than the one we have on file.

Print form and send to:

Privacy Office
CIGNA
PO Box 188014
Chattanooga, TN 37422

Personal Representative Request Form*

Use when you want to enable a person other than yourself to act on your behalf with respect to your CIGNA Medicare plan.

Print form and send to:

Privacy Office
CIGNA
PO Box 188014
Chattanooga, TN 37422

Access to HealthCare Information Form

Use when you want to request access to protected health information that we have created or received.

Print form and send to:

Privacy Office
CIGNA
PO Box 188014
Chattanooga, TN 37422