Home
Forms Library
Aetna phi access request form

Phi legal form 2025

aetna phi access request form Preview on Page 1

See details

4.8 out of 5

155 votes

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 outlines the necessary information required from both the member and subscriber, details the types of PHI reports available, and provides instructions for completing and submitting the form. Additionally, it includes legal notices regarding the handling of sensitive health information and options for language assistance.

Here's how it works

01. Edit your aetna phi access request form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send aetna protected health information via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out phi legal form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

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 the subscriber is not the member whose records are requested, complete this section with their details.
In Section 3, specify your request for PHI Access Reports. Indicate if you want data from a specific date range or if you prefer to include FSA or LTC information.
Section 4 requires a signature from the recipient of the PHI Access Report. Ensure that any legal representatives provide necessary documentation.
If sending records to someone other than those listed in Section 4, complete Section 5 with authorization details.
Finally, return the completed form as instructed at the bottom of the document.

Start using our platform today to easily fill out and manage your phi legal forms online for free!

See more phi legal form versions

We've got more versions of the phi legal form form. Select the right phi legal form version from the list and start editing it straight away!

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

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the purpose of the release information form?

The primary purpose of an ROI form is to legally authorize the disclosure of personal information, such as: Medical Records: health history, diagnoses, and treatments. Financial Records: billing, payments, and insurance claims. Legal Information: relevant documents for litigation or claims.

What qualifies for PHI?

The Privacy Rule calls this information protected health information (PHI). Individually identifiable health information is information, including demographic data, that relates to: the individuals past, present or future physical or mental health or condition, the provision of health care to the individual, or.

What is a PHI form used for?

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.

What does PHI tell us?

PHI is information created or received by a healthcare provider relating to: The past, present or future physical or mental health or condition of a patient; The provision of healthcare to an individual; or.

What is the purpose of the 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.

aetna phi access form

Phi legal form template Phi legal form pdf HIPAA release form PDF Printable HIPAA release form Free printable release of information form PDF HIPAA authorization form for family members Authorization for release of information form Phi legal form online

What are the 4 types of PHI?

Protected health information (PHI) is any combination of factors that can be used to identify a patient. It includes information about the patients physical/mental health condition, payment for services provided, and their care team. It can take any format, including verbal, written, and email communications.