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Get Aetna GR-67938 S 2019-2024

Authorization For Release Of Protected Health Information I hereby authorize Aetna Life Insurance Company and any of its parents subsidiaries and affiliates including but not limited to Aetna Health Management Inc. Aetna s affiliated HMOs and Aetna Integrated Informatics and their respective agents and subcontractors to disclose confidential information about the member/insured identified below. I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY. Please Print All Responses If you do not fill out both sides of this form completely Aetna may be unable to process your request. Authorization For Release Of Protected Health Information I hereby authorize Aetna Life Insurance Company and any of its parents subsidiaries and affiliates including but not limited to Aetna Health Management Inc* Aetna s affiliated HMOs and Aetna Integrated Informatics and their respective agents and subcontractors to disclose confidential information about the member/insured identified below. I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY. Please Print All Responses If you do not fill out both sides of this form completely Aetna may be unable to process your request. Incomplete authorization requests will be returned to you. 1. Member/Insured Information Last Name First Name Member I. D. Number Social Security Number Street Address Middle Initial Birthdate MM/DD/YYYY Daytime Telephone Number include area code City State and Zip Code 2. I authorize the individual s or company ies identified below to receive confidential health information pertaining to the member/insured named above. Individual or company authorized to receive confidential information 3. Purpose s for this Authorization This authorization is for Aetna To respond to all requests for confidential information made by the individual s or company ies named in Section 2 above. To respond to requests for only the following specific information for example disclosures about claims submitted by a specific provider If this authorization is limited to information in effect for a specific period of time please indicate through mm/dd/yyyy 4. Type of coverage to which this authorization applies check all that apply Disability Long Term Care Health This includes medical dental pharmacy vision and flexible spending accounts 5. Description of the information to be released or disclosed check all that are appropriate Application or enrollment information* Claim records Claim status Patient management records Other please specify GR-67938 5-03 R-POD 6. IMPORTANT Your signature below means that you understand and agree to the following The protected health information provided under this authorization may include diagnosis and treatment information including information pertaining to chronic diseases behavioral health conditions alcohol or substance abuse communicable diseases including HIV/AIDS and/or genetic marker information* These records will be included in the information we will make available to the individual s or company ies identified in Section 2 above.

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