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The form requires completing all sections including member identity and contact details, selecting which record categories can be shared, and choosing an authorization purpose. It explains sensitivity risks, limits (e.g., psychotherapy notes), validity for up to one year, cancellation rights, and signature requirements, including state-specific conditions.","Authorization for Release of ECHS Category-PHIA Protected Health Information (PHI)  \nMy health record is private and is known under the law as “Protected Health Information” (PHI) . By completing and signing this form, I, or my legal representative, agree to allow Aetna to share my PHI with the people or companies listed below. By Aetna, I also mean the company’s subsidiaries, affiliates, employees, agents and subcontractors. PLEASE COMPLETE ALL SECTIONS.  \n1. My information  \n\n| My first name |  | Last name |  | Middle initial |\n| --- | --- | --- | --- | --- |\n| My member ID number | My birth date (MMDDYYYY) |  | My phone number |  |\n| My street |  |  | My city, state, ZIP code |  |\n\n2. Aetna can share my PHI with the following people or companies:  \n\n| Person or company name | Phone number |\n| --- | --- |\n| Street | City, state and ZIP code |\n| Person or company name | Phone number |\n| Street | City, state and ZIP code |\n\n3. Aetna can share ONLY my records chosen below.  \nYou must check any and all information that you want to be shared. This authorization cannot be used to share psychotherapy notes.  \n Health (medical, dental, pharmacy, vision and flexible spending account information)  Long term care  Patient management records  \n Substance use disorder (alcohol/drug)  HIV/AIDS  Sexually transmitted diseases  Behavioral health/Mental health (but NOT psychotherapy notes) .  \n Other sensitive services (such as gender affirming care or sexual or reproductive health)  \n Other (please explain)    \n4. By signing this form I authorize Aetna to disclose information below for the following purpose.  \nCheck one of the following options:  \n At my request – no specific purpose  Specific purpose:    \n5. This form will be valid for 1 year unless a shorter time period is listed below.  \n\n| My authorization is valid from\u003Cbr>MM/DD/YYYY | to  \u003Cbr>MM/DD/YYYY |\n| --- | --- |\n\nGR-67938-39 (7-22) MEDICARE-Aetna  \n6. By signing below, I understand and agree:  \n• My PHI that I agree to share may be sensitive. It may include diagnosis and treatment information. It may cover chronic diseases, behavioral health conditions and alcohol or drug abuse. It may cover communicable diseases, sexually transmitted diseases such as HIV/AIDS, and genetic marker information.  \n• Whoever gets my PHI may share it with others. That means federal or state privacy laws may no longer protect my PHI.  \n• I can get a copy of this authorization form that I have signed by sending Aetna a signed request using the address at the bottom of this form.  \n• Aetna will not release my PHI to the individual(s) or company(ies) named in Section 2 unless I sign this form.  \n• I can cancel or change my decision any time. I can do this by writing to Aetna, using the address atthe bottom of this form.  \n• If I do cancel my permission, it will not affect actions Aetna took before getting my request.  \n• My ability to enroll won’t change if I do not sign this form.  \n• My eligibility for benefits and services won’t change if I do not sign this form.  \nATTENTION:  \nMy signature is required if any of the below apply:  \n• I am 18 years of age or older  \n• I am a minor under the age of 18 and I am either married or I am emancipated  \n• The information being disclosed pertains to drug or alcohol treatment  \n• The information being disclosed pertains to one of the following conditions and my state allows me to be treated even if my parents or legal guardian do not agree with my decision:  \n- Mental health  \n- Sexually transmitted disease (including HIV/AIDS)  \n- Reproductive health (including contraception, prenatal care and abortion)  \n- General medical and dental health  \n7. My signature or my legal representative’s signature  \n\n| Signature | Date |\n| --- | --- |\n| Print name |  |\n| If a legal representative signed this form, describe the relationship: (parent, legal guardian, Power of Attorney, personal representative) |  |\n\n• If this request is being signed by the member’s legal representat","cbCaimJaWC2EY9yL","https://ap.wps.com/l/cbCaimJaWC2EY9yL","pdf",1294811,3,"English","en",105,"# My information\n# People or companies Aetna can share my PHI with\n# Records Aetna can share (selection)\n# Purpose of disclosure (select)\n# Authorization validity period\n# Understand and agree (signature requirements)\n# My signature or legal representative signature","[{\"question\":\"Who is authorized to sign this PHI release form?\",\"answer\":\"The member or the member’s legal representative can sign. 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If a legal representative signs, legal documentation authorizing them must be provided, and additional information may be required for minor children.","Answer",{"name":126,"@type":121,"acceptedAnswer":127},"What types of records can be shared under this authorization?",{"text":128,"@type":124},"Aetna can share only the record categories selected in Section 3, covering options such as health information, long term care, substance use disorder, HIV/AIDS, sexually transmitted diseases, behavioral/mental health (but not psychotherapy notes), and other sensitive services if selected.",{"name":130,"@type":121,"acceptedAnswer":131},"How long is this authorization valid and can it be canceled?",{"text":132,"@type":124},"The form is valid for 1 year unless a shorter period is listed. The member can cancel or change their decision any time by writing to Aetna, and cancellation does not affect actions Aetna took before receiving the request.","https://schema.org",{"og:url":94,"og:type":135,"og:title":59,"og:site_name":106,"og:description":60},"article",{"robots":137,"canonical":94},"index,follow",{"doc_id":55,"site_id":69},1790176353]