Authorization/Notification to Release Protected Health Information
CIGNA Medical Group
required areas must be completed or this release will be considered invalid.
Please fill out sections 1 through 4 if requesting information from your Medical Chart/Pharmacy Profile.
fill out sections 1, 2, 3 and 5 if requesting x-ray films and/or other diagnostic images.
Please fill out section 1 through 4 if requesting "Other" types of health information, please specify.
. Form must be completed in ink.
FOR CIGNA USE ONLY
NO. PAGES RELEASED:
RECORDS PREPARED AND TRANSMITTED BY (PRINT NAME):
RECIPIENT - PRINT NAME (as listed in Part 2 only):
DATE REQUEST RECEIVED:
PART 1. PATIENT INFORMATION
DATE OF BIRTH:
ADDRESS (Street, City, State, Zip Code):
PART 2. DESTINATION OF RECORDS
I hereby authorize CIGNA HealthCare of Arizona to release medical record