Authorized Representative Request
FAX Number
Name and Dates of Service or Proposed Service
I,
Print the name of the member who is receiving the service or supply
, do hereby name
Print the name of the person who is being authorized to act on the member’s behalf
to act as my authorized representati
ve in requesting (check one)
a complaint or an appeal from Aetna regarding the
above-noted service or proposed service.
IMPORTANT: Your signature below means that you understand and agree to the following:
● In conjunction with this (check one)
complaint or appeal, Aetna may disclose Protected Health Information (“PHI”)
to the above-named authorized representative (“Representative”).
● The PHI disclosed pursuant to this authorization may include diagnosis and treatment information, including
information pertaining to chronic diseases, behavioral health conditions, alcohol or substance abuse,
communicable diseases, sexually-transmitted diseases, HIV/AIDS, and/or genetic marker information.
● Information disclosed pursuant to this authorization may be redisclosed by the Representative and may no longer be
protected by federal or state privacy regulations.
● If you would like to pursue (check one)
a complaint or an appeal, at the Representative’s request, but do not want
the Representative to receive any PHI or other information related to the (check one)
complaint or appeal,
including the (check one)
complaint or appeal, decision, you may indicate that choice by checking the box on the
signature line below.
● Your ability to enroll in an Aetna plan, and your eligibility for benefits and payment for services, will not be affected if you
do not sign this form. However, without your signature, we cannot process the (check one)
complaint or appeal,
initiated by the Representative.
● This authorization is only valid for the duration of the (check one)
complaint or appeal. If you sign this form, you
may revoke the authorization at any time by notifying Aetna in writing at the address above. Revoking this authorization
will not have any effect on actions that Aetna took in reliance on the authorization before we received the notification.
Please accept this (check one) complaint or appeal, from my representative on my behalf; however, forward all
information related to this (check one)
complaint or appeal, including the (check one) complaint or appeal
decision and any request you may have for additional information, to my attention only.
If person signing this Authorization is not the Member, describe relationship to the Member (i.e. Parent, Legal
Representative)
Legal Representatives signing this authorization on behalf of a Member must furnish a copy of a health care power of attorney, or other relevant document
that grants the applicable legal authority.
GR-68910 (3-15)
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signature
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