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Get and Sign Echs Phia 2014-2022 Form
Submit a separate Authorization form for each Member for whom Aetna is being requested to disclose PHI. If this form is
not completed, as applicable, Aetna will be unable to process your request. Incomplete authorization requests will be returned.
PLEASE PRINT YOUR RESPONSES.
1. Member Information
Last Name
I.D. Number
First Name
Social Security Number
Street Address
Middle Initial
Birth Date (MM/DD/YYYY) Daytime Telephone Number (include area code)
City, State and ZIP Code
2. Subscriber...
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