Fillable THIS fOrM wIll AllOw ME, AS A CIGNA HEAlTHCArE* CuSTOMEr, TO rEquEST ACCESS TO PrOTECTED HEAlTH INfOrMATION (PHI) ABOuT ME THAT CIGNA HEAlTHCArE MAINTAINS AND THAT wAS CrEATED Or rECEIVED BY CIGNA HEAlTHCArE DurING THE TIME Of MY COVErAGE

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Request for Access to Protected Health Information THIS fOrM wIll AllOw ME, AS A CIGNA HEAlTHCArE * CuSTOMEr, TO rEquEST ACCESS TO PrOTECTED HEAlTH INfOrMATION (PHI) ABOuT ME THAT CIGNA HEAlTHCArE MAINTAINS AND THAT wAS CrEATED Or rECEIVED BY CIGNA HEAlTHCArE DurING THE TIME Of MY COVErAGE wITH THE PlAN IDENTIfIED BElOw. VERIFICATION (Please Print) Identification of Customer requesting PHI: (The following...
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