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.

Attachments must be sent under separate cover and will not be secured. If you need to send an attachment, please send to:

Email:
   privacyofficer@geha.com

Mail:
   GEHA
   Attn: Privacy Officer
   P.O. Box 438
   Independence, MO 64051-0438

This is a secured form. Please complete the appropriate information below as well as entering an explanation in the Question/Issue box and select submit to send this form by email to GEHA Compliance Department.

About You

First Name

Middle Initial

Last Name *

Do you reside within the United States?

Yes No

If YES, please enter your U.S. mailing address.

City *

State AA AE Alabama Alaska AP Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Other Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming *

ZIP Code *

If NO, please enter your Overseas Address

Primary Phone Number

Alternate Phone Number

Email Address

Whose privacy was breached?

Member ID Number (if known) *

Member First Name (if known)

Member Middle Initial (if known)

Member Last Name (if known) *

Patient First Name (if known)

Patient Middle Initial (if known)

Patient Last Name (if known) *

What is the complaint?

Type of Complaint Access Amendment Accounting of Disclosures Authorizations Breach of Confidentiality Confidential Communication Notice of Privacy Practices Restrictions Security Other

Please select the appropriate item in regard to the area of privacy and/or security that you feel has been breached.

Complaint Description

In the comment box above, please provide the following information: Date(s) issue occurred; name(s) of individual(s) involved (if any); what occurred.