Protected Health Information (PHI) Access Request Form 2026

1. Click ‘Get Form’ to open the Protected Health Information (PHI) Access Request Form in the editor.
2. Begin by filling out Section 1, which requires Member Information. Enter the Last Name, First Name, I.D. Number, Social Security Number, Street Address, Middle Initial, Birth Date, Daytime Telephone Number, and City, State and Zip Code.
3. In Section 2, provide Subscriber Information if applicable. This includes similar fields as Section 1: Last Name, First Name, I.D. Number, Street Address, Social Security Number, Middle Initial, Birth Date, Daytime Telephone Number, and City, State and Zip Code.
4. Section 3 allows you to specify your request for PHI Access Reports. Indicate if you want the most recent 24 months of claim data or a different date range by filling in the 'From' and 'To' fields.
5. Complete Section 4 by selecting the recipient of the PHI Access Report and providing their signature and address details.
6. If necessary, fill out Section 5 for Authorization for Release of PHI. Ensure all required signatures are provided.
7. Finally, return the completed form to Aetna Legal Support Services as instructed in Section 6.

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