08/05/2019
1
PHI10/R11
ENR-1495-PHI10
GE-FRM-0219-001
0I
REQUEST FOR CONFIDENTIAL COMMUNICATIONS BY
ALTERNATIVE MEANS OR ALTERNATIVE LOCATIONS
Use this form to request that GEHA communicate with you using a different means or location.
About you, the GEHA member requesting confidential communications
Plan ID Number:
Member Name: _______ Date of Birth: _______________________
Address:
Telephone Number:
Please place a check mark in front of each plan you want this Access request to be applied:
___ GEHA Health Plan ___GEHA Connection Dental Federal Plan
___ Connection Dental Plus Plan ___CONNECTION Vision Plan
New Contact Information
New Address:
New Telephone:
Reason for Request:
Please complete the following regarding your confidential communications request:
Will the failure to communicate your Protected Health Information through an alternative location endanger you?
Yes No
Signature and Acknowledgement
• I understand that any request GEHA accepts will be limited to information under GEHA’s control, and the request
will be communicated to GEHA’s Business Associates.
• I have the right to request GEHA terminate the confidential communication to the extent that such termination
applies to information created or received after the date of termination, by contacting the Privacy Office at the
address below or at privacyofficer@geha.com.
Date:
Patient or Legal Representative Signature:
Relationship to patient:
(i.e. parent, legal guardian, power of attorney, etc.)
NOTE: If the signature is not that of the patient or the parent when the child is a minor, appropriate legal documentation
is required to accept the signature.
click to sign
signature
click to edit
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