Get Phi Request Form

The phi request form is essential for individuals seeking access to their protected health information. This guide provides a clear, step-by-step approach to assist users in completing the form accurately and effectively.

Follow the steps to complete the phi request form online

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by filling out Section 1, which pertains to the member information. Enter the last name, first name, I.D. number, social security number, street address, middle initial, birth date, daytime telephone number, city, state, and ZIP code of the person whose records you are requesting.
3. If necessary, complete Section 2 for subscriber information. This section is required if the subscriber is not the member whose records are requested. Provide the last name, first name, I.D. number, street address, social security number, middle initial, birth date, daytime telephone number, city, state, and ZIP code.
4. In Section 3, describe the specific PHI access reports you are requesting. You have the option to receive medical, dental, and pharmacy claim data from the last 24 months or specify a different date range by filling in the 'From' and 'To' fields. Include a checkmark for any FSA or Long Term Care information if applicable.
5. Proceed to Section 4 to identify the recipient of the PHI Access Report, which may include the member, their legal representative, or parent. Ensure the recipient's information is correctly filled out, including obtaining the necessary signatures.
6. Complete Section 5 if the report is to be sent to someone other than the member or their legal representative. This section involves authorizing Aetna to disclose the protected health information to a designated recipient. Include necessary signatures in this section as well.
7. Once all sections are completed, review your entries for accuracy. Save your changes and opt to download, print, or share the form, ensuring it is sent to Aetna Legal Support Services as outlined in Section 6.

Complete your phi request form online today for easy access to your health information.