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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 |
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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:
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If you want to identify someone else who will make health care decisions for you, use this form: |
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, |
CareAllies Health Care Privacy Forms |
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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: |
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, |
Cigna Global Health Benefits Privacy Forms |
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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
Canadian Customers CLIC Consent to Disclose Personal Health Information Privacy Office |
Cigna Medical Group Forms |
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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. |
Cigna Medicare Services Privacy Forms |
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Need help finding something?
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