Privacy Forms
The forms on this page are to be used to submit requests for Cigna, its affiliates, and subsidiaries.
Cigna Health Care and Behavioral Health Privacy Forms
The following forms are used to submit requests for Cigna Health Care and 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
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 Restrictions
English [PDF] Español [PDF] Chinese [PDF] - Request for Confidential Communications for Vermont Resident Crime Victims
English [PDF] - Fax state specific forms to
1 (877) 815-4827 or(859) 410-2419 . You can also call the phone number on the back of your Cigna ID card and 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
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
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
CareAllies Health Care Privacy Forms
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 Care Allies maintains, use this form:
Request for Access to Protected Health Information
If you want to identify someone else who will make health care decisions for you, use this form:
Request for Personal Representative
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
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:
CareAllies Privacy Office HIPAA UNIT,
PO Box 188014,
Chattanooga, TN 37422
Cigna Global Health Benefits Privacy Forms
Use these if you are a Cigna International customer.
If you need to make a request mentioned in the "Cigna Global Health Benefits Notice of Privacy Practices," you must provide the request in writing. You can either send a written request or provide one of the forms listed below.
To use a form to submit a request, select the appropriate link to print the form you need. Please send all signed and completed forms to the address below.
U.S. Customers
- HIPAA Authorization:
English [PDF] Español [PDF] Chinese [PDF] - HIPAA Confidential Communication:
English [PDF] Español [PDF] Chinese [PDF] - HIPAA Personal Representative:
English [PDF] Español [PDF] Chinese [PDF] - HIPAA Request for Restriction:
English [PDF] Español [PDF] Chinese [PDF] - HIPAA Request for Access:
English [PDF] Español [PDF] Chinese [PDF] - HIPAA Request to Amend:
English [PDF] Español [PDF] Chinese [PDF] - HIPAA Request for an Accounting of Disclosures:
English [PDF] Español [PDF] Chinese [PDF] - Request for Diagnosis and Treatment Code Information:
English [PDF] Español [PDF] Chinese [PDF]
Canadian Customers
Privacy Office
Cigna Global Health Benefits
300 Bellevue Parkway
Wilmington, DE 19809
Evernorth Care Group Forms
Use these if you are a Evernorth Care Group customer. Evernorth Care Group is the group practice division of Cigna HealthCare of AZ.
Please note: Evernorth Care Group will not disclose confidential information without your authorization unless it is necessary to provide your treatment, pay your Medical Group claims, administer health benefits, 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. The Privacy Notice that each Evernorth Care Group patient receives from his/her physician describes more fully how we use your information. You may also read a copy of the Evernorth Care Group Privacy Notice on this Web site.
Cigna Medicare Services Privacy Forms
Health Care Claims
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Disclaimer
Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see
All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. This website is not intended for residents of New Mexico.