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Aetna phi access request form

Phi legal form 2025

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The document is a Protected Health Information (PHI) Access Request Form for Aetna, which allows individuals to request access to their or their dependents' health records. It includes sections for member and subscriber information, options for specific PHI reports, and authorization for release of information. The form must be completed and returned to Aetna's HIPAA Member Rights Team, with instructions on how to fill it out and legal requirements for representatives.

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Click ‘Get Form’ to open the phi legal form in the editor.
In Section 1, enter the Member Information. Fill in the last name, first name, I.D. number, social security number, street address, middle initial, birth date, daytime telephone number, and city/state/ZIP code.
Proceed to Section 2 for Subscriber Information if applicable. Complete this section only if the subscriber is not the member whose records are being requested.
In Section 3, specify your request for PHI Access Reports. Indicate if you want data from a specific date range or include FSA/LTC information by checking the appropriate boxes.
Section 4 requires a signature from the recipient of the PHI Access Report. Ensure that all necessary legal documents are attached if signed by a representative.
If sending records to someone other than those listed in Section 4, complete Section 5 with authorization details and signatures as required.
Finally, return the completed form to the specified address or fax number provided at the end of the document.

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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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What is PHI in legal terms?

PHI stands for Protected Health Information. The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information.

What are the 7 identifiers of PHI?

What Are the 18 HIPAA Identifiers for PHI? Patient names. Geographical elements (such as a street address, city, county, or zip code) Dates related to the health or identity of individuals (including birthdates, date of admission, date of discharge, date of death, or exact age of a patient older than 89)

Who is eligible for PHI?

If the oldest person is under 65 years old Income for surcharge purposesRebate for 1 July 2022 31 March 2023 $90,000 or less for a single person 24.608% $90,001 $105,000 for a single person 16.405% $105,001 $140,000 for a single person 8.202% $140,001 or more for a single person Not eligible4 more rows

What are the 7 patient rights of private health information?

Patient rights under HIPAA encompass the right to access and obtain copies of their health information, the right to request corrections to their records, the right to receive privacy notices, the right to control the sharing of their health information, the right to file complaints about privacy violations, the right

What qualifies as PHI under HIPAA?

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.

aetna phi access form

Phi legal form pdf Phi legal form requirements HIPAA release form PDF HIPAA authorization form for family members HIPAA release form California Printable HIPAA release form Authorization for release of information form Phi legal form online

What is PHI forms?

What is 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 qualifies for PHI?

PHI under HIPAA covers any health data created, transmitted, or stored by a HIPAA-covered entity and its business associates. It includes electronic records (ePHI), written records, lab results, x-rays, bills even verbal conversations that include personally identifying information.

What are the 4 types of PHI?

All formats of PHI records are covered by HIPAA. These include (but are not limited to) spoken PHI, PHI written on paper, electronic PHI, and physical or digital images that could identify the subject of health information.