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Aetna behavioral health member choice form

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The document is a Behavioral Health/Medical Provider Communication Form designed to facilitate the exchange of important patient information between medical and behavioral health providers. It includes sections for patient and provider details, diagnosis, medications, risks, and patient rights regarding the authorization of information disclosure. The form emphasizes patient consent and confidentiality, particularly concerning sensitive health information.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient information. Fill in the patient's name, street address, birth date, insurance ID number, and daytime telephone number. If the patient does not have a medical provider, check the appropriate box.
Next, provide the medical provider's details including their name, address, city, state, and telephone number. Repeat this for the behavioral health provider as well.
In the communication section, detail important information about the patient such as diagnosis, medications/herbal remedies with dosages, and any risks or concerns.
Review the Patient Rights section carefully. Ensure you understand your rights regarding authorization before proceeding.
Finally, complete the Patient Authorization section by selecting one of the options for releasing information and signing with your date.

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