Authorization for Release of Personal
Confidential Information to Third Parties
I hereby authorize Aetna and any of its parents, subsidiaries, or other affiliates (including, but not limited to, Aetna
Health Management, Inc., Aetna Life Insurance Company, U.S. Quality Algorithms), and their respective agents and
subcontractors, to disclose confidential information about the member/insured listed below.
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 the member.
I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY and that the information to be disclosed
may be protected by law.
Member/Insured Name
Aetna I.D. or Social Security Number
Date of Birth
Name and Aetna I.D. or social security number of subscriber, if different from Member/Insured
(
)
Street Address
City, State, and Zip Code
Daytime Telephone Number
I authorize the individual or company identified below to receive confidential information pertaining to the
member/insured named above.
Individual or company authorized to receive confidential information
Street Address
City, State, & Zip Code
(
)
Daytime Telephone Number
Information to be disclosed to this individual or company includes application or enrollment information,
eligibility information, claims records, claim status, and patient management records.
Disclosure requested will include otherwise confidential medical information. If our records include claims or
other information pertaining to chronic diseases, behavioral health conditions, including 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 or company designated above.
Type of coverage to which this authorization applies (check all that apply):
MEDICAL
DENTAL
DISABILITY
PHARMACY
PENSION
LONG TERM CARE
LIFE
Other (specify)
Continued on other side
B-POD
GR-67809 (2-02)
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