Privacy Forms 

Description:

Use this form to allow someone such as a spouse, attorney, or associate to access to your Protected Health Information (PHI).

How to Submit:

To expedite your request, submit an Electronic Privacy Form on myCigna, or

Use a paper privacy form if one of the following applies:

• You need a form in a different language.
• You are completing a form for a dependent under age 13.
• If you have a court-appointed personal representative or guardian, there is a power of attorney, or there is a need to attach legal or other documentation.

If completing a paper form, please follow these steps:

• Fill in the appropriate form online.
• Print the form to sign.
• Mail or fax to the address indicated on the form.

Paper Privacy Forms: English [PDF]   Español [PDF]   Chinese [PDF]

Please note: If you wish to only remove a CA Sensitive Services restriction, check the State Sensitive Services box and complete only sections 1 and 6 on the form.

Description:

Use this form to enable another individual to act on your behalf with respect to:

• Making decisions about your health benefits.
• Requesting and/or disclosing PHI.
• Exercising all your rights under your health plan.

How to Submit:

To expedite your request, submit an Electronic Privacy Form on myCigna, or

Use a paper privacy form if one of the following applies:

• You need a form in a different language.
• You are completing a form for a dependent under age 13.
• If you have a court-appointed personal representative or guardian, there is a power of attorney, or there is a need to attach legal or other documentation.

If completing a paper form, please follow these steps:

• Fill in the appropriate form online.
• Print the form to sign.
• Mail or fax to the address indicated on the form.

Paper Privacy Forms: English [PDF]   Español [PDF]   Chinese [PDF]

Description:

Use this form to receive Cigna Healthcare communications of PHI about yourself by alternative means or at alternative locations and/or request a restriction of the use and disclosure of your PHI to:

• Restrict anyone from gaining access to your PHI.
• Have all correspondence go to an alternative physical address.
• Do both of the above.

On the form, you will need to indicate what type of privacy restriction you are electing (such as denying others access which can include a Primary Care Provider).

• Request for Confidential Communications for Vermont Resident Crime Victims: English [PDF]

Fax state specific forms to 1 (877) 815-4827 or 1 (859) 410-2419. You can also call the phone number on the back of your ID card and speak with a Customer Service Associate.

How to Submit:

To expedite your request, submit an Electronic Privacy Form on myCigna, or

Use a paper privacy form if one of the following applies:

• You need a form in a different language.
• You are completing a form for a dependent under age 13.
• If you have a court-appointed personal representative or guardian, there is a power of attorney, or there is a need to attach legal or other documentation.

If completing a paper form, please follow these steps:

• Fill in the appropriate form online.
• Print the form to sign.
• Mail or fax to the address indicated on the form.

Paper Privacy Forms: English [PDF]   Español [PDF]   Chinese [PDF]

Description:

Use this form when you want to obtain a copy of some or all your PHI that Cigna Healthcare maintains, such as:

• Claims
• Eligibility
• Case management/medical utilization

Other PHI (i.e., appeals, coaching notes, Employee Assistance Program (EAP) records, call notes, etc.)

How to Submit:

To expedite your request, submit an Electronic Privacy Form on myCigna, or

Use a paper privacy form if one of the following applies:

• You need a form in a different language.
• You are completing a form for a dependent under age 13.
• If you have a court-appointed personal representative or guardian, there is a power of attorney, or there is a need to attach legal or other documentation.

If completing a paper form, please follow these steps:

• Fill in the appropriate form online.
• Print the form to sign.
• Mail or fax to the address indicated on the form.

Paper Privacy Forms: English [PDF]   Español [PDF]   Chinese [PDF]

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

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

Request for Access to Protected Health Information
English [PDF]   Español [PDF]   Chinese [PDF]

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

Request for Personal Representative
English [PDF]   Español [PDF]   Chinese [PDF]

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

Authorization for Disclosure of Protected Health Information
English [PDF]   Español [PDF]   Chinese [PDF]

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