Authorized-Representative-Request-Form. Accessible PDF 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the FAX Number and Member Name at the top of the form. Ensure that the Aetna ID Number is accurately filled in for identification purposes.
3. In the 'Provider of Service' section, specify the name of the service provider along with the relevant dates of service or proposed service.
4. Clearly print your name in the designated area to authorize someone to act on your behalf. This person will be referred to as your authorized representative.
5. Select whether you are requesting a complaint or an appeal by checking the appropriate box.
6. Review and check any boxes regarding disclosure of Protected Health Information (PHI) as per your preferences, ensuring you understand what information may be shared.
7. Sign and date the form at the bottom, and if applicable, indicate your relationship to the member if you are not signing as them.

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