Cigna Form Sp1813 PDF Details

Managing healthcare information often involves navigating through a sea of paperwork, and the Cigna SP1813 form is a key document within this realm, especially for members of the Cigna Medical Group. Primarily, this form functions as an authorization or notification document that allows for the release of protected health information to specified parties. Its meticulous composition necessitates a complete and ink-written submission across various sections tailored to the type of health information being requested – whether it's medical chart details, x-ray films, diagnostic images, or a pharmacy profile. Crucially, it outlines the requirements for releasing records, including patient information, the destination of records, the purpose of the release, and specifics regarding the types of records requested. Special emphasis is given to the nature of the request, distinguishing between personal use, continuing care, or other purposes, each potentially incurring different processing fees and timeframes. Moreover, the form addresses the sensitivity and confidentiality of certain information categories, including HIV-related, communicable diseases, alcohol or drug abuse treatment program information, psychotherapy notes, and genetic testing results, thereby reinforcing the importance of handling such data with utmost discretion and legality. Consent terms highlighted within the form underline a patient's autonomy over their health information, detailing the conditions under which this authorization can be revoked, thereby adding a layer of personal security and control. The inclusion of specific notices for recipients about the restrictions on further disclosure of the information underscores a commitment to maintaining confidentiality in compliance with both state and federal laws.

QuestionAnswer
Form NameCigna Form Sp1813
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesAuthorization Release_PHI Eng cigna sp1813 form

Form Preview Example

Pharmacy Profile
Co-Pay Statement

 

.

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

 

 

 

 

 

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).

Copies of records of the last (2) years of treatment

Copies of records covering dates from ______________ to _____________

Laboratory Results (Dates): ______________________________________

Other (Please specify):

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

White: Chart Copy

Yellow: Requestor

File: Legal/Correspondence

 

 

IMPORTANT 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.

How to Edit Cigna Form Sp1813 Online for Free

With the online editor for PDFs by FormsPal, you're able to complete or change Cigna Form Sp1813 right here and now. To keep our editor on the forefront of efficiency, we work to integrate user-oriented features and improvements on a regular basis. We are routinely thankful for any feedback - help us with revampimg PDF editing. Here's what you'll have to do to get started:

Step 1: Press the "Get Form" button above on this webpage to access our PDF editor.

Step 2: Using our online PDF editor, you can actually accomplish more than simply complete forms. Express yourself and make your docs seem sublime with custom textual content added in, or modify the original content to excellence - all comes along with the capability to add any images and sign it off.

This document will involve specific information; to guarantee correctness, you need to consider the following recommendations:

1. To get started, while filling in the Cigna Form Sp1813, start with the part containing next blanks:

Stage no. 1 in filling in Cigna Form Sp1813

2. Soon after the prior array of fields is completed, proceed to enter the relevant information in all these: Date of Appointment, Other Please indicate purpose of, PART TYPE OF RECORDS BEING, Requests normally take business, CoPay Statement, Copies of records of the last, Copies of records covering dates, Laboratory Results Dates, Pharmacy Profile, Other Please specify, PART XRAY FILMS DIAGNOSTIC IMAGES, Reports Only A fee may apply for, For, XRay Exam Date, and Films Only A fee may apply for.

The best ways to complete Cigna Form Sp1813 portion 2

People frequently make errors while completing CoPay Statement in this section. Be sure you go over whatever you type in here.

3. Through this part, examine I authorize the release of, PATIENT SIGNATURE, DATE, PARENT GUARDIAN POWER OF ATTORNEY, RELATIONSHIP TO PATIENT, WITNESSNOTARY, DATE, SP Rev, White Chart Copy Yellow Requestor, and File LegalCorrespondence. All of these must be filled out with highest accuracy.

Tips to prepare Cigna Form Sp1813 stage 3

Step 3: Immediately after proofreading the filled out blanks, press "Done" and you're all set! Sign up with us right now and instantly access Cigna Form Sp1813, ready for downloading. Every last modification you make is handily saved , enabling you to customize the pdf at a later time as needed. Here at FormsPal.com, we endeavor to make certain that all of your information is stored secure.

Cigna Form Sp1813 isn’t the one you’re looking for?

Related Documents