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CIGNA Medicare Rx (PDP) Privacy Forms
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:
CIGNA Medicare Services
PO Box 269005
Weston, FL 33326-9927
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:
CIGNA Medicare Services
PO Box 269005
Weston, FL 33326-9927
Revoke Change 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:
CIGNA Medicare Services
PO Box 269005
Weston, FL 33326-9927
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:
CIGNA Medicare Services
PO Box 269005
Weston, FL 33326-9927
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:
CIGNA Medicare Services
PO Box 269005
Weston, FL 33326-9927
Amend PHI Form
Use when you want to request an amendment to the protected health information that we maintain.
Print form and send to:
CIGNA Medicare Services
PO Box 269005
Weston, FL 33326-9927
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:
CIGNA Medicare Services
PO Box 269005
Weston, FL 33326-9927
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:
CIGNA Medicare Services
PO Box 269005
Weston, FL 33326-9927
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:
CIGNA Medicare Services
PO Box 269005
Weston, FL 33326-9927
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