Health Care and Behavioral 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. The forms are also to be used for Cigna Behavioral Health.

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 or obtain a copy of your health care diagnosis and treatment code information, use this form:
Request for Access to Protected Health Information English | Español | Chinese 

If you want to receive Cigna correspondence at a confidential address or limit who your health care information is released to or how it is used, use this form:

• Request for Confidential Communications or Restriction Request: English | Español | Chinese
• 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 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 

Written requests for an amendment to your PHI, an accounting of disclosures, statement of disagreement, or to change/revoke a prior request, may be mailed to:
Cigna HEALTHCARE CENTRAL HIPAA UNIT,
PO Box 188014,
Chattanooga, TN 37422