The Cigna SP1813 is an authorization form that allows members of the Cigna Medical Group network to request the release of their protected health information (PHI) to approved individuals or organizations. Whether the purpose is a personal health records request, continuing care, or an insurance claim, this form provides a legally compliant method for authorized disclosure of health data.
This authorization form covers several categories of medical documentation. You may request medical chart information, x-ray films, diagnostic images, a pharmacy profile, CoPay statement records, laboratory results covering specific dates, and other relevant health documents. Each record type may require a separate section of the form to be completed. Requests for films or diagnostic images may carry a separate processing fee from the insurance plan.
For x-ray films and diagnostic images, the form distinguishes between requesting reports only and requesting the physical films. Reports may be provided at no additional cost from the Cigna insurance plan, while copies of actual films may incur a fee. Review the fee schedule with your Cigna plan before submitting.
The form identifies several accepted purposes for releasing health information. Common reasons include personal use, continuing care by another provider, insurance claim processing, and other authorized purposes. The purpose of the release determines how the company handles the records and whether additional fees apply. Requests for continuing care are often processed faster than general personal use requests.
The patient, a parent or guardian, or a person holding power of attorney may complete and sign the authorization. A witness or notary may also be required depending on the type of records being requested. All fields must be filled out in ink to ensure the form is valid and accepted by the Cigna Medical Group insurance company.
The form includes specific provisions for sensitive information categories. These include HIV-related data, communicable disease records, alcohol or drug abuse treatment program information, psychotherapy notes, and genetic testing results. Disclosure of these record types carries additional legal protections under both state and federal law. The form clearly outlines recipient restrictions to prevent further unauthorized disclosure of this sensitive health data.
You may revoke your authorization at any time by providing written notice to Cigna Medical Group. Once the company receives your revocation, further disclosure of your records will stop, unless records were already disclosed prior to the revocation request. Review the consent terms included in the form for full details about your rights and responsibilities under this authorization.
| Question | Answer |
|---|---|
| Form Name | Cigna Form Sp1813 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Authorization Release_PHI Eng cigna sp1813 form |