Authorization for Release of Confidential Information to Third Parties (continued)
IMPORTANT: Your signature below means that you understand and agree to the following:
Requests for paper copies of claims and encounter information we receive from the individual or company
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you have authorized to receive your confidential information, require payment of a $10 administrative fee
(except where prohibited by law) to defray our copying and mailing costs. Requests for paper copies
should be accompanied by a check or money order made payable to Aetna Inc. in the amount of $10 for
each member whose records are requested.
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You understand that your eligibility for benefits and payment for services covered by Aetna under your
plan will not be affected if you do not sign this form. (However, without your signature, your request to
release the information described above to a third party will not be honored.)
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The confidential information provided to the authorized individual or company upon their request, may
include diagnosis and treatment information, including information on chronic diseases, behavioral health
conditions, including alcohol or substance abuse, communicable diseases, including HIV/AIDS, and/or
genetic marker information.
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You understand that you may receive a copy of this form if you ask for it by writing to the address listed at
the bottom of this page.
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You understand this authorization will expire one year from the date you sign this authorization. You also
understand that if you sign this form, you may revoke the authorization at any time by notifying Aetna in
writing, but if you do that, it won’t have any effect on actions that Aetna took before we received the
notification.
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You agree to hold Aetna Inc. and its affiliates harmless from any claim or liability (including, but not
limited to, any claim brought under a confidentiality or privacy law) in connection with the release at your
request of the information and records described above.
Signature of Member/Insured or Legal Representative
Date
Print name of Member/Insured's Legal Representative (if applicable)
Relationship to Member/Insured
If this authorization is being requested by member/insured's legal representative, you must furnish a copy of the power
of attorney, or other relevant document designating you as the representative.
(Important note: the witness below may not be the person authorized to receive the information to be disclosed.)
Witnessed by:
Printed name of witness
Date
Signature of witness
Return the completed form to:
Aetna Law Document Center
151 Farmington Avenue, W121
Hartford, CT 06156-9998
Please provide a copy of this form to your authorized representative so that they will be able to establish the validity of
their request for your health information.
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