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Privacy Complaint Form

This form is for use in reporting any privacy or HIPAA compliance concerns to GEHA's Privacy Office.

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

Email: privacy@geha.com

• Mail: ATTN: Privacy Officer, GEHA, P.O. Box 21542, Eagan, MN 55121

About You

A member of the Privacy Office will contact you to confirm receipt of your complaint and gather any additional information needed for review. The Privacy Office will follow-up at the end of our review, using this contact information.

Name (optional)

Address (optional)

Phone Number (optional)

Email Address (optional)

Does your complaint involve the private information of an individual employee or GEHA member? If so, please complete this section with as much information as is known.

Name of Impacted Individual (optional)

Address (optional)

GEHA Member Plan ID (optional)

Please select the applicable plan below, if known:

Health plan (optional)

Dental plan (optional)

Vision plan (optional)

What is your concern

Name of GEHA employee involved (if known) (optional)

Brief description of your concerns. Please give all the dates and other details that you can remember.

If you are not the impacted individual, what is your relationship to GEHA? For example, Member, Provider, Employee, etc. (optional)