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| Form Title: | CIGNA Authorization for Use and Disclosure of Private Health Information Form |
| Last Revised: | 04/2003 |
| Purpose: | Employees requesting assistance from Human Resources on specific claims or on claims for a specific period of time. Blanket authorizations are not allowed. |
| Who Should Use the Form: | Employees with the CIGNA insurance medical and/or dental plans. |
| Instructions: | Employee completes the form, signs and submits to Human Resources who then forwards it to CIGNA. |
| The Form: | Form in .pdf format |
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