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The document is a Protected Health Information (PHI) Access Request Form for Aetna, which must be completed and signed to request access to a member's health records. It includes sections for member and subscriber information, details on the type of PHI access requested, and authorization for release of information. The form outlines the process for obtaining a PHI Access Report that includes medical, dental, and pharmacy claim data for the past 24 months or other specified periods. It also provides instructions on returning the form and important notices regarding the nature of the information disclosed.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (155 Votes)
2018	4 Satisfied (33 Votes)
2004	4.3 Satisfied (114 Votes)

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Which of the following are forms of PHI?

What are Examples of PHI? Email Addresses. Email addresses qualify as PHI when tied to health-related communications. Fax Numbers. Vehicle Numbers. Certificates or License Numbers. Full Face Imagery. MRI Scans. Social Security Numbers. Account Numbers.

What documentation forms are PHI?

PHI includes sensitive information, such as medical histories, test results, and insurance information. Protecting this information is crucial for preserving patient confidentiality. A breach can lead to repercussions such as identity theft or personal harm, emphasizing the need for stringent security measures.

What document forms are PHI?

Protected health information (PHI) is any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment.

What is a PHI access form?

A HIPAA release form, also known as a HIPAA authorization or HIPAA consent form, is a legal document signed by an individual to grant permission for their protected health information (PHI) to be used by authorized individuals at covered entities for specific purposes other than treatment, payment, and health care

What documents does not contain PHI?

Employee and education records: Any records concerning employee or student health, such as known allergies, blood type, or disabilities, are not considered PHI. Wearable devices: Data collected by wearable devices such as heart rate monitors or smartwatches is not PHI.

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What records are considered PHI?

What is protected health information (PHI)? Names. Birth dates and healthcare service dates (aside from the year) Telephone numbers. Geographic data other than the state they live in, such as the street address, city, county, or ZIP code. FAX numbers. Social Security numbers. Email addresses. Medical record numbers.

How do I request PHI?

The individuals request must be in writing, signed by the individual, and clearly identify the designated person or entity and where to send the PHI.

Get the up-to-date Protected Health Information (PHI) Access Request Form 2025 now

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How to modify Protected Health Information (PHI) Access Request Form in PDF format online

See more Protected Health Information (PHI) Access Request Form versions

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Which of the following are forms of PHI?

What documentation forms are PHI?

What document forms are PHI?

What is a PHI access form?

What documents does not contain PHI?

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What records are considered PHI?

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