Fillable Authorization for Release of Protected Health Information (PHI) (Aetna Health Insurance)

Fill Online, Printable, Fillable, Blank Authorization for Release of Protected Health Information (PHI) (Aetna Health Insurance) Form

Use Fill to complete blank online AETNA HEALTH INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Authorization for Release of Protected Health Information (PHI) (Aetna Health Insurance)

On average this form takes 8 minutes to complete

The Authorization for Release of Protected Health Information (PHI) (Aetna Health Insurance) form is 2 pages long and contains:

  • 1 signature
  • 10 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Aetna Health Insurance forms online.

BROWSE AETNA HEALTH INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Authorization for Release of
Protected Health Information (PHI)
ECHS Category - PHIA
My health record is private and is known under the law as “Protected Health Information” (PHI).
By completing and signing this form, I, or my legal representative, agree to allow Aetna to share my PHI
with the people or companies listed below. By Aetna, I also mean the company’s subsidiaries, affiliates,
employees, agents and subcontractors. PLEASE COMPLETE ALL SECTIONS.
1. My information
My first name Last name Middle initial
My member ID number My birth date (MMDDYYYY) My phone number
My street My city, state, ZIP code
2. Aetna can share my PHI with the following people or companies:
Person or company name Phone number
Street City, state and ZIP code
Person or company name Phone number
Street City, state and ZIP code
3. Aetna can share ONLY my records chosen below.
You must check any and all information that you want to be shared. This authorization cannot be used
to share psychotherapy notes.
Health (medical, dental, pharmacy, vision and flexible spending account information)
Long term care Patient management records
Substance use disorder (alcohol/drug) HIV/AIDS Sexually transmitted diseases
Behavioral health/Mental health (but NOT psychotherapy notes).
Other (please explain)
4. By signing this form I authorize Aetna to disclose information below for the
following purpose.
Check one of the following options:
At my request – no specific purpose Specific purpose:
5. This form will be valid for 1 year unless a shorter time period is listed below.
My authorization is valid from
MM/DD/YYYY
to
MM/DD/YYYY
GR-67938 (5-19) S R-POD
6. By signing below, I understand and agree:
My PHI that I agree to share may be sensitive. It may include diagnosis and treatment information.
It may cover chronic diseases, behavioral health conditions and alcohol or drug abuse. It may
cover communicable diseases, sexually transmitted diseases such as HIV/AIDS, and genetic
marker information.
Whoever gets my PHI may share it with others. That means federal or state privacy laws may
no longer protect my PHI.
I can get a copy of this authorization form that I have signed by sending Aetna a signed request
using the address at the bottom of this form.
Aetna will not release my PHI to the individual(s) or company(ies) named in Section 2 unless I sign
this form.
I can cancel or change my decision any time. I can do this by writing to Aetna, using the address at
the bottom of this form.
If I do cancel my permission, it will not affect actions Aetna took before getting my request.
My ability to enroll won’t change if I do not sign this form.
My eligibility for benefits and services won’t change if I do not sign this form.
ATTENTION:
My signature is required if any of the below apply:
I am 18 years of age or older
I am a minor under the age of 18 and I am either married or I am emancipated
The information being disclosed pertains to drug or alcohol treatment
The information being disclosed pertains to one of the following conditions and my state allows
me to be treated even if my parents or legal guardian do not agree with my decision:
Mental health
Sexually transmitted disease (including HIV/AIDS)
Reproductive health (including contraception, prenatal care and abortion)
General medical and dental health
7. My signature or my legal representative’s signature
Signature Date
Print name
If a legal representative signed this form, describe the relationship: (parent, legal guardian, Power of
Attorney, personal representative)
• If this request is being signed by the member’s legal representative, you must provide legal
documentation authorizing you to act on the member’s behalf (e.g., legal guardianship, power of
attorney, personal representative).
• If you are making this request on behalf of a minor child, we may require additional information
before this request is considered complete.
Please sign and return this completed form to:
HIPAA Member Rights Team
PO Box 14079
Lexington, KY 40512-4079
Or you can fax it to: 859-280-1272
GR-67938 (5-19) S Page 2 of 6
click to sign
signature
click to edit
Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate,
exclude or treat people differently based on their race, color, national origin, sex, age, or disability.
We provide free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services,
call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a
protected class noted above, you can also file a grievance with the Civil Rights Coordinator by
contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO
customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.
You can also
file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or
at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F,
HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provide
d by one or more of the Aetna group
of subsidiary companies.
GR-67938 (5-19) S Page 3 of 6
TTY:711
English To access language services at no cost to you, call the number on your ID card.
Albanian
Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj
të identitetit.
Amharic
የቋንቋ አገልግሎቶችን ያለክፍያ ለማግኘት፣ በመታወቂያዎት ላይ ያለውን ቁጥር ይደውሉ
Arabic 
Armenian
Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար
զանգահարեք ձեր բժշկական ապահովագրության քարտի վրա նշված
հէրախոսահամարով
Bantu-Kirundi
Kugira uronke serivisi z'indimi ata kiguzi, hamagara inomero iri ku karangamuntu
kawe
Bengali
Burmese
Catalan
Per accedir a serveis lingüístics sense cap cost per a vostè, telefoni al número
indicat a la seva targeta d’identificació.
Cebuano
Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran, tawagi ang
numero nga anaa sa imong kard sa ID.
Chamorro
Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu
kard aidentifikasion.
Cherokee
ᏩᎩᏍᏗ ᎦᏬᏂᎯᏍᏗ ᎢᏅᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ ᎾᏍᎩ ᏗᏎᏍᏗ
ᏥᏕᎪᏪᎵ ᎤᎾᎢ ID ᏆᏂᏲᏍᏗ ᏣᏤᎵᎢ.
Chinese Traditional 如欲使用免費語言服務，請撥打您健康保險卡上所列的電話號碼
Choctaw
Anumpa tosholi i toksvli ya peh pilla ho ish i payahinla kvt chi holisso kallo iskitini
holhtena takanli ma i payah
Chuukese
Ren omw kopwe angei aninisin eman chon awewei (ese kamé), kopwe kééri ewe
nampa mei mak won noum ena katen ID
Cushitic-Oromo
Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa fuula waraaqaa
eenyummaa (ID) kee irraa jiruun bilbili.
Dutch
Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart.
French
Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro
indiqué sur votre carte d'assurance santé.
French Creole
(Haitian)
Pou ou jwenn sèvis gratis nan lang ou, rele nimewo telefòn ki sou kat idantifikasyon
asirans sante ou.
German
Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die
Nummer auf Ihrer ID-Karte an.
Greek
Για πρόσβαση στις υπηρεσίες γλώσσας χωρίς χρέωση, καλέστε τον αριθμό στην
κάρτα ασφάλισής σας.
Gujarati
Hawaiian
No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu
kāleka ID. Kāki ʻole ʻia kēia kōkua nei.
Hindi
Hmong
Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm
koj daim npav ID.
GR-67938 (5-19) S Page 4 of 6
Igbo
Inweta enyemaka asụsụ na akwughi ụgwọ obụla, kpọọ nọmba nọ na kaadi
njirimara gị
Ilocano
Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti
numero nga adda ayan ti ID kardmo.
Indonesian
Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor
telepon di kartu asuransi Anda.
Italian
Per accedere ai servizi linguistici senza alcun costo per lei, chiami il numero sulla
tessera identificativa.
Japanese
無料の言語サービスは、 IDカードにある番号にお電話ください。
Karen
Korean
무료 다국어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해
주십시오.
Kru-Bassa
I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye
ntilga i kat yong matibla
Kurdish
ID (

Lao
Marathi
Marshallese
Micronesian-
Ponapean
Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw
doaropwe en ID.
Mon-Khmer,
Cambodian
Navajo
Nepali
Nilotic-Dinka
Norwegian
For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.
Pennsylvanian-
Dutch
Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.
Persian Farsi 
Polish
Aby uzyskać dostęp do bezpłatnych usług językowych, należy zadzwonić pod numer
podany na karcie identyfikacyjnej.
Portuguese
Para aceder aos serviços linguísticos gratuitamente, ligue para o número indicado
no seu cartão de identificação.
Punjabi
Romanian
Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul de membru.
Russian
Для того чтобы бесплатно получить помощь переводчика, позвоните по
телефону, приведенному на вашей идентификационной карте.
GR-67938 (5-19) S Page 5 of 6
Samoan
Mō le mauaina o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i
luga o lau pepa ID.
Serbo-Croatian
Za besplatne prevodilačke usluge pozovite broj naveden na Vašoj identifikacionoj
kartici.
Spanish
Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura
en su tarjeta de identificación.
Sudanic Fulfulde
Heeɓa a naasta nder ekkitol jaangirde woldeji walla yoɓugo, ewnu lamba je ɗon
windi ha do ɗerowol maaɗa.
Swahili
Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya
kitambulisho.
Syriac-Assyrian
Tagalog
Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang
numero sa iyong ID card.
Telugu
Thai
Tongan
Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa,
telefoni ki he fika ‘oku hā atu ‘i ho’o ID kaati.
Turkish
Dil hizmetlerine ücretsiz olarak erişmek için kimlik kartınızdaki numarayı arayın.
Ukrainian
Щоб безкоштовнj отримати мовні послуги, задзвоніть за номером, вказаним на
вашій ідентифікайній картці.
Urdu
Vietnamese
Để sử dụng các dịch vụ ngôn ngữ miễn phí, vui lòng gọi số điện thoại ghi trên thẻ ID
của quý vị.
Yiddish
.לטראק ID רעייא ףיוא רעמונ םעד טפור ,לאצפא ןופ יירפ סעסיוורעס ךארפש ןעמוקאב וצ
Yoruba
GR-67938 (5-19) S Page 6 of 6
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Authorization for Release of Protected Health Information (PHI) (Aetna Health Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document