Cigna Privacy Forms

If you want to allow someone else (such as a spouse, friend or attorney) to access your health care information, use this form:

• Member Release of Information Form
• Directions for the Member Release of Information Form

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

• Request for Confidential Communications Form
• Request for Confidential Communications for Oregon Residents
• Request for Confidential Communications for Vermont Resident Crime Victims
• Email or fax these state specific forms to behrhfr@cigna.com, 1 (860) 687-9438 or call the number on your Cigna ID card and ask to speak with a Customer Service Associate.

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 and Disclosure of Private Health Information Form

If you want to identify someone else who will make health care decisions for you, use this form:

• Personal Representative Request Form

If you want to obtain a copy of your health care information that Cigna maintains, use this form:

• Request for Access to Healthcare Information Form

If you want to either request a change to or cancel any of the above requests, use this form:

• Change/Revoke Request Form

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 Form

If you want to disagree with Cigna's denial of your request to amend your health care information, use this form:

• Statement of Disagreement/Request to Forward Denial of Amendment Request Form

If you want to amend or correct health care information that Cigna created, use this form:

• Request to Amend Private Health Information Form