Breach of Privacy and/or Security Form

Home
FAQs & Resources
Form & Document Library
Breach of Privacy and/or Security Complaint Form
Breach of Privacy and/or Security Form

Account Sign In

Not registered yet? Register Now

Forgot Password?

GEHA Newsletters & Updates

Enter your email address to sign up for the Health e-Report, our monthly newsletter...

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 *

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

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.