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The form collects member and provider details, the date or service period, and the representative’s identity. It explains how Protected Health Information (PHI) may be disclosed, what PHI can include, risks of redisclosure, conditions for limiting PHI access, and rules on signature validity, revocation, and processing.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorized-representative-request-submission-instructions-complaint-or-appeal/288459/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorized-representative-request-submission-instructions-complaint-or-appeal/288459.png","ImageObject",442,249,{"name":88,"@type":89},"นรินทร์","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who should be named on this form as the authorized representative?","Question",{"text":108,"@type":109},"The member must print the name of the person receiving the authorization to act on the member’s behalf for the complaint or appeal.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What does signing the authorization indicate?",{"text":113,"@type":109},"By signing, the member confirms understanding and agreement that Aetna may disclose Protected Health Information to the authorized representative for the checked complaint or appeal.",{"name":115,"@type":106,"acceptedAnswer":116},"Can the member revoke the authorization, and what happens then?",{"text":117,"@type":109},"Yes. The authorization is valid only for the duration of the checked complaint or appeal, and it may be revoked at any time by notifying Aetna in writing; revocation does not affect actions Aetna took before receiving the notice.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288459,1789633507,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":9},2336475104957,"https://ap-avatar.wpscdn.com/avatar/22000c4c6bd8a5076e1?x-image-process=image/resize,m_fixed,w_180,h_180&k=1787554080175789136","Authorized Representative Request  \nFAX Number  \n\n| Member Name | Aetna ID Number |\n| --- | --- |\n| Provider of Service |  |\n| Name and Dates of Service or Proposed Service |  |\n\nI, , do hereby name  \nPrint the name of the member who is receiving the service or supply  \nPrint the name of the person who is being authorized to act on the member’s behalf  \nto act as my authorized representative in requesting (check one)  \n a complaint or  an appeal from Aetna regarding the above-noted service or proposed service.  \nIMPORTANT: Your signature below means that you understand and agree to the following:  \n● In conjunction with this (check one)  complaint or  appeal, Aetna may disclose Protected Health Information (“PHI”) to the above-named authorized representative (“Representative”) .  \n● The PHI disclosed pursuant to this authorization may include diagnosis and treatment information, including information pertaining to chronic diseases, behavioral health conditions, alcohol or substance abuse, communicable diseases, sexually-transmitted diseases, HIV/AIDS, and/or genetic marker information .  \n● Information disclosed pursuant to this authorization may be redisclosed by the Representative and may no longer be protected by federal or state privacy regulations.  \n● If you would like to pursue (check one)  a complaint or  an appeal, at the Representative’s request, but do not want the Representative to receive any PHI or other information related to the (check one)  complaint or  appeal, including the (check one)  complaint or  appeal, decision, you may indicate that choice by checking the box on the signature line below.  \n● Your ability to enroll in an Aetna plan, and your eligibility for benefits and payment for services, will not be affected if you do not sign this form. However, without your signature, we cannot process the (check one)  complaint or  appeal, initiated by the Representative.  \n● This authorization is only valid for the duration of the (check one)  complaint or  appeal. If you sign this form, you may revoke the authorization at any time by notifying Aetna in writing at the address above. Revoking this authorization will not have any effect on actions that Aetna took in reliance on the authorization before we received the notification.  \n Please accept this (check one)  complaint or  appeal, from my representative on my behalf; however, forward all information related to this (check one)  complaint or  appeal, including the (check one)  \n complaint or  appeal decision and any request you may have for additional information, to my attention only.  \n\n| Signature | Date |\n| --- | --- |\n| Print Name |  |\n| If person signing this Authorization is not the Member, describe relationship to the Member (i.e. Parent, Legal Representative) |  |\n\nLegal Representatives signing this authorization on behalf of a Member must furnish a copy of a health care power of attorney , or other relevant document that grants the applicable legal authority.  \nGR-68910 (8-25)  \nTTY: 711  \n\n| English | To access language services at no cost to you, call the number on your ID card. |\n| --- | --- |\n| Amharic | የቋንቋ አገልግሎቶችን ያለክፍያ ለማግኘት፣ በመታወቂያዎት ላይ ያለውን ቁጥር ይደውሉ፡፡ |\n| Arabic | ٔ\u003Cbr>.ﻟﻠﺤﺼﻮل ﻋﻠﯽ اﻟﺤخ ﺪﻣﺎٮت اﻟﻠﻌخ ﻮتيﻪت دوںخ اى تت ﻜﻠفخ ﻪت ، اﻟﺮﺣب ﺎء اﻟﺼﺎل ﻋﻠﯽ اﻟﺮفت ﻢ اﻟﻤﻮﺣب ﻮد ﻋﻠﯽ ىب ﻄﺎفت ﻪت اﺳش تت ﺮاﻛكك\u003Cbr>ي |\n| Armenian | Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար զանգահարեք ձերբժշկական ապահովագրության քարտի վրա նշված հէրախոսահամարով հէրախոսահամարով |\n| Carolinian\u003Cbr>(Kapasal Falawasch) | Ngir mëna am sarwis lakk yi te doo fay, woo nimero bi am ci sa kàrt. |\n| Chamorro | Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard aidentifikasion. |\n| Chinese Traditional | 如欲使用免費語言服務，請撥打您健康保險卡上所列的電話號碼 |\n| Cushitic-Oromo | Tajaajiiloota afaanii gatii bilisaa ati argaachuuf, lakkoofsa fuula waraaqaa eenyummaa (ID) kee irraajiruun bilbili. |\n| French | Pour accéder gratuitement aux services linguistiques, veuil","cbCaikZqbLn3wtAT","https://ap.wps.com/l/cbCaikZqbLn3wtAT","pdf",852757,"English","# Authorized Representative Request\n## Member and Service Details\n## Authorization Statements and PHI Disclosure\n## Signature, Date, and Legal Representative Requirements","[{\"question\":\"Who should be named on this form as the authorized representative?\",\"answer\":\"The member must print the name of the person receiving the authorization to act on the member’s behalf for the complaint or appeal.\"},{\"question\":\"What does signing the authorization indicate?\",\"answer\":\"By signing, the member confirms understanding and agreement that Aetna may disclose Protected Health Information to the authorized representative for the checked complaint or appeal.\"},{\"question\":\"Can the member revoke the authorization, and what happens then?\",\"answer\":\"Yes. The authorization is valid only for the duration of the checked complaint or appeal, and it may be revoked at any time by notifying Aetna in writing; revocation does not affect actions Aetna took before receiving the notice.\"}]","Authorized Representative Request - Submission Instructions - Complaint or Appeal | PDF"]