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
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 Restrictions
  English   Español   Chinese
• Request for Confidential Communications for Vermont Resident Crime Victims
  English
• Email or fax state specific forms to CHUSI@cigna.com, 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 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

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
English   Español   Chinese

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:

CareAllies Privacy Office HIPAA UNIT,
PO Box 188014,
Chattanooga, TN 37422

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   Español   Chinese 
• HIPAA Confidential Communication:
  English   Español   Chinese 
• HIPAA Personal Representative:
  English   Español   Chinese 
• HIPAA Request for Restriction:
  English   Español   Chinese 
• HIPAA Request for Access:
  English   Español   Chinese 
• HIPAA Request to Amend:
  English   Español   Chinese 
• HIPAA Request for an Accounting of Disclosures:
  English   Español   Chinese 
• Request for Diagnosis and Treatment Code Information:
  English   Español   Chinese 

Canadian Customers

CLIC Consent to Disclose Personal Health Information

CLIC Privacy Notice

Privacy Office
Cigna Global Health Benefits
300 Bellevue Parkway
Wilmington, DE 19809

Use these if you are a Cigna Medical Group customer. Cigna Medical Group is the group practice division of Cigna HealthCare of AZ.

Authorization/Notification to Release Protected Health Information-English

Authorization/Notification to Release Protected Health Information-Spanish

Request to Amend Personal Health Information (ENG) (SPA)

Request for Restriction on Disclosure of Personal Health Information

Request for Representative (ENG) (SPA)

Change/Revocation Request (ENG) (SPA)

Notification of Privacy/Confidential Communication (ENG) (SPA)

Please note: Cigna Medical 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 Cigna Medical Group patient receives from his/her physician describes more fully how we use your information. You may also read a copy of the Cigna Medical Group Privacy Notice on this Web site.

Privacy forms for Cigna Medicare Rx

Privacy forms for Cigna Medicare Select Plus Rx (HMO)