Form Sp 1813 - Authorization Notification Form To Release Protected Health Info Cigna

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Authorization/Notification to Release Protected Health Information
.
C
IGNA 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
MRN:
CL:
NO. PAGES RELEASED:
DATE REQUEST RECEIVED:
RECORDS PREPARED AND TRANSMITTED BY (PRINT NAME):
SIGNATURE:
DATE:
RECIPIENT - PRINT NAME (as listed in Part 2 only):
SIGNATURE:
DATE:
PART 1. PATIENT INFORMATION
PATIENT NAME:
DATE OF BIRTH:
IDENTIFICATION NUMBER:
DAYTIME PHONE:
HOME PHONE:
ADDRESS (Street, City, State, Zip Code):
PART 2. DESTINATION OF RECORDS
I hereby authorize CIGNA HealthCare of Arizona to release medical records information concerning the above-named patient to:
RECIPIENT’S NAME:
RECIPIENT’S PHONE NUMBER:
ADDRESS (Street, City, State, Zip Code):
PART 3. PURPOSE OF RELEASE
PLEASE NOTE:
Fees are applicable if the nature of the request is for other than the patient’s continuation of care. If this section is left blank, CIGNA
assumes that the request is for personal use and fees will apply.
Purpose of Request:
Continuation of Care (Future Appointment)
Personal Use (Please see current Fee Schedule)
Other (Please indicate purpose of request):
Date of Appointment:_____________________
PART 4. TYPE OF RECORDS BEING REQUESTED
PLEASE NOTE:
Requests normally take 10 business days for processing; but, please allow 30 days from the request date for receipt at the given
destination (as listed in Part 2).
Co-Pay Statement
Copies of records of the last (2) years of treatment
Pharmacy Profile
Copies of records covering dates from ______________ to _____________
Other (Please specify):
Laboratory Results (Dates): ______________________________________
PART 5. X-RAY FILMS / DIAGNOSTIC IMAGES
Reports Only (A fee may apply for copies)
For:
X-Ray Exam: ______________________________________________ Date: _______________
Films Only (A fee may apply for copies)
X-Ray Exam: ______________________________________________ Date: _______________
Films and Reports (A fee may apply for copies)
X-Ray Exam: ______________________________________________ Date: _______________
Permanent Transfer of Mammograms (All)
X-Ray Exam: ______________________________________________ Date: _______________
I authorize the release of photocopies of the following medical records and/or diagnostic images in the possession or control of CIGNA HealthCare of
Arizona, its employees and/or agents. FOR THE PURPOSE HEREOF, "MEDICAL RECORDS" AND "DIAGNOSTIC IMAGES" SHALL INCLUDE ALL:
1. CONFIDENTIAL HIV-RELATED INFORMATION (AS DEFINED IN A.R.S. SECTION 36-661).
2. CONFIDENTIAL COMMUNICABLE DISEASE-RELATED INFORMATION (AS DEFINED IN A.R.S. SECTION 36-661).
3. CONFIDENTIAL ALCOHOL OR DRUG ABUSE TREATMENT PROGRAM INFORMATION (AS DEFINED IN 42 CFR SECTION 2.1 ET SEQ).
4. CONFIDENTIAL PSYCHOTHERAPY NOTES. (AS DEFINED IN 42 CFR SECTION 164.501).
5. CONFIDENTIAL GENETIC TESTING INFORMATION (AS DEFINED IN A.R.S. SECTION 12-2801).
I hereby release you, your physicians, and your employees from any and all liability for fulfilling the authorization request for release of medical information.
I understand it is possible that the information in my medical records may be disclosed by the recipient to other parties. This consent will expire ninety (90)
days after the signed date below. I have given my consent freely, voluntarily and without coercion. I may revoke this authorization at any time providing I
notify CIGNA HealthCare of Arizona in writing to that effect. I understand that any releases, which were made prior to my revocation in compliance with this
authorization, shall not constitute a breach of my rights to confidentiality. Certain information concerning a minor is governed by AZ State and Federal
statutes and will require the minor’s signature prior to any release. I understand that a photocopy/facsimile of this authorization is considered acceptable in
lieu of the original.
PATIENT SIGNATURE:
DATE:
PARENT / GUARDIAN / POWER OF ATTORNEY:
RELATIONSHIP TO PATIENT:
WITNESS/NOTARY:
DATE:
SP1813 Rev. 01-05
File: Legal/Correspondence
White: Chart Copy
Yellow: Requestor

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