Form Sp 1813 - Authorization Notification Form To Release Protected Health Info Cigna Page 2
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2IMPORTANT INFORMATION/NOTES FOR THE RECIPIENT:
It is CIGNA Medical Group’s practice to release (upon authorization and/or notification) photocopies of
medical records and/or x-ray films from the last two (2) years of treatment received unless otherwise
requested by the patient. There may be additional records/medical information available. The patient is
required to sign a specific authorization for the additional information to be released. For all continuing care
requests, additional information will be provided upon request of the Physician.
Redisclosure Prohibited: The information disclosed to you is confidential and protected by law. Any further
disclosure may be strictly prohibited under applicable law. For example, if you received any medical records
and/or x-ray films which included genetic test or genetic testing information as defined in A.R.S. Section
12-2801, further disclosure of the test information and results is prohibited under Arizona law without the
specific written consent of the person to whom it pertains or as otherwise permitted by law.
In addition, if you received any medical records and/or for x-ray films which included confidential HIV-related
information or confidential communicable disease-related information as defined in A.R.S. Section 36-661, the
following notice on redisclosure applies under Arizona law:
THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM CONFIDENTIAL RECORDS
WHICH ARE PROTECTED BY STATE LAW THAT PROHIBITS FURTHER REDISCLOSURE OF
THE INFORMATION WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO
WHOM IT PERTAINS OR AS OTHERWISE PERMITTED BY LAW (A.R.S. SECTION 36-664 (G)).
THIS DOES NOT APPLY TO THE PROTECTED PERSON OR A PROTECTED PERSON’S
HEALTH CARE DECISION MAKER.
Further, if you received any medical records and/or x-ray films which included confidential alcohol or drug
abuse-related information as defined in 42 CFR Section 2.1 et seq., the following notice on redisclosure
applies under the federal law.
THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS PROTECTED BY
FEDERAL CONFIDENTIALITY RULES (42 CFR PART II). THE FEDERAL RULES PROHIBIT
YOU FROM MAKING ANY FURTHER DISCLOSURE OF THIS INFORMATION UNLESS
FURTHER DISCLOSURE IS EXPRESSLY PERMITTED BY THE WRITTEN CONSENT OF THE
PERSON TO WHOM IT PERTAINS OR AS OTHERWISE PERMITTED BY 42 CFR PART II. A
GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS
NOT SUFFICIENT FOR THIS PURPOSE. THE FEDERAL RULES RESTRICT ANY USE OF THE
INFORMATION TO CRIMINALLY INVESTIGATE OR PROSECUTE ANY ALCOHOL OR DRUG
ABUSE PATIENT.
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