Breach of Privacy and/or Security Complaint Form

Effective April 14, 2003, a complaint about a potential breach of privacy and/or security may be filed with GEHA in regard to the privacy or security regulations of the Health Insurance Portability and Accountability Act (HIPAA). Please include as much information as possible regarding how you feel a breach may have occurred to assist us in reviewing the issue.

You can use the "Fill out online" link below to securely send the information electronically to GEHA, or you can click the "Download" link to open a PDF version of the form to print, complete and return to GEHA by mail.

This form can also be delivered to you by U.S. mail if you call GEHA Customer Service at 800.821.6136 and request it.