Health Care Privacy Forms

The following forms are used to submit requests mentioned in the Notices of Privacy Practices for Cigna HealthCare and Cigna Home Delivery Pharmacy.

To make a request, print and complete the appropriate form and mail it to the address indicated on the form.

If you want to obtain a copy of your health care information that Cigna maintains, use this form:
Request for Access to Protected Health Information English | Español | Chinese 

If you want to amend or correct health care information that Cigna created, use this form:
Request to Amend Protected Health Information English | Español | Chinese 

If you want to learn whether Cigna has released any of your health care information to a third party, use this form:
Request for Accounting English | Español | Chinese 

If you want to limit who your health care information is released to or how it is used, use this form:
Request for Restriction of Use English | Español | Chinese

If you want to receive Cigna correspondence at a confidential address, use this form:

• Request for Confidential Communications English | Español | Chinese
• Request for Confidential Communications for Oregon Residents English
• Request for Confidential Communications for Vermont Resident Crime Victims English
  • Email or fax state specific forms to  CHUSI@cigna.com, 877.815.4827 or 859.410.2419 or call the phone number on the back of your Cigna ID card and ask to speak with a Customer Service Associate

If you want to identify someone else who will make health care decisions for you, use this form:
Request for Personal Representative English | Español | Chinese 

If you want to disagree with Cigna's denial of your request to amend your health care information, use this form:
Statement of Disagreement-Amendment Request English | Español | Chinese 

If you want to either request a change to or cancel any of the above requests, use this form:
Change/Revoke Request - English | Español | Chinese 

If you want to allow someone else (such as a spouse, friend or attorney) to access your health care information, use this form:
Authorization for Disclosure of Protected Health Information English | Español | Chinese 

If you want to obtain a copy of your health care diagnosis and treatment code information that Cigna maintains, use this form:
Request for Diagnosis and Treatment Code Information English | Español | Chinese 
Request for Diagnosis and Treatment Code Information Form (for Starbridge/Fundamental Care Limited Benefit Health Plans)