Arizona Authorization To Release Protected Health InformationArizona Authorization To Release Protected Health Information
Download the document to the computer for easy use
There are more pages to preview,Read on

Clear Fields

Authorization/Notification to Release Protected Health Information

CIGNA Medical Group

.. All
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.
.. Please
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
CL:

MRN:

NO. PAGES RELEASED:

RECORDS PREPARED AND TRANSMITTED BY (PRINT NAME):

SIGNATURE:

RECIPIENT - PRINT NAME (as listed in Part 2 only):

DATE REQUEST RECEIVED:
DATE:

SIGNATURE:

DATE:

PART 1. PATIENT INFORMATION
PATIENT NAME:

DATE OF BIRTH:
DAYTIME PHONE:

IDENTIFICATION NUMBER:

HOME PHONE:

ADDRESS (Street, City, State, Zip Code):

PART 2. DESTINATION OF RECORDS
I hereby authorize CIGNA HealthCare of Arizona to release medical record