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Privacy Forms
The forms on this page are to be used to submit requests for Cigna Healthcare, its affiliates, and subsidiaries.
Cigna Healthcare and Behavioral Health Privacy Forms
The following forms are used to submit requests for Cigna HealthcareSM and Behavioral Health.
To expedite your request, 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.
Authorization for Disclosure of Protected Health Information
Description: Use this form to allow someone such as a spouse, attorney, or associate to access to your Protected Health Information (PHI).
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.
Authorization for Disclosure of Protected Health Information: English [PDF] Español [PDF] Chinese [PDF]
Personal Representative 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.
All correspondence will go only to the Personal Representative address.
Request for Personal Representative: English [PDF] Español [PDF] Chinese [PDF]
Request Confidential Communications or Restrictions Form
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 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 or1 (859) 410-2419 . You can also call the phone number on the back of your ID card and speak with a Customer Service Associate.
Request for Access to Protected Health Information Form
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.)
Request for Access to 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:
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
English [PDF] Español [PDF] Chinese [PDF]
If you want to identify someone else who will make health care decisions for you, use this 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 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
Cigna Global Health Benefits Privacy Forms
Use these if you are a Cigna Healthcare 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
CLIC Consent to Disclose Personal Health Information [PDF]
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.
Authorization/Notification to Release Protected Health Information-English [PDF]
Authorization/Notification to Release Protected Health Information-Spanish [PDF]
Request to Amend Personal Health Information (ENG) (SPA) [PDF]
Request for Restriction on Disclosure of Personal Health Information [PDF]
Request for Representative (ENG) (SPA) [PDF]
Change/Revocation Request (ENG) (SPA) [PDF]
Notification of Privacy/Confidential Communication (ENG) (SPA) [PDF]
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 Healthcare Medicare Services Privacy Forms
Health Care Claims
If you need to file a health care claim, we have forms for medical, dental, family leave, and more.
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Disclaimer
Product availability may vary by location and plan type and is subject to change. All health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna Healthcare representative.
All Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North 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 a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of The Cigna Group Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT). The Cigna Healthcare name, logo, and other Cigna Healthcare marks are owned by Cigna Intellectual Property, Inc. This website is not intended for residents of Arizona and New Mexico.
La aseguradora publica el formulario traducido para fines informativos y la versión en inglés prevalece para fines de solicitud e interpretación.
The insurer is issuing the translated form on an informational basis and the English version is controlling for the purposes of application and interpretation.