Fillable 0I 9/13/19 HIPAA COMPLAINT FORM About You This (GEHA)

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0I 9/13/19 HIPAA COMPLAINT FORM About You This (GEHA)

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The 0I 9/13/19 HIPAA COMPLAINT FORM About You This (GEHA) form is 1 page long and contains:

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  • 17 other fields

Country of origin: US
File type: PDF

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9/13/19
PHI03/R10
ENR-1705-PHI03
GE-FRM-0119-008
0I
HIPAA COMPLAINT FORM
This form is for use in reporting any HIPAA concerns to GEHA’s Privacy Office.
About You
Name:
Address:
Contact telephone number during business hours:
Whose Information Is Your Complaint Regarding
Subscriber Name (if known):
Address (if known):
Subscriber ID Number (if known): Telephone Number (if known):
Patient Name (if known): Date of Birth (if known):
Please select the applicable Plan below, if known:
___ GEHA Health Plan ___GEHA Connection Dental Federal Plan
___ Connection Dental Plus Plan ___CONNECTION Vision Plan
What Is Your Concern
Name of GEHA employee involved (if known):
Brief description of the event. Please give all the dates and other details that you can remember.
Date:
Signature:
Relationship (if not patient):
PLEASE RETAIN A COPY FOR YOUR RECORDS AND RETURN THE ORIGINAL SIGNED COMPLAINT FORM TO:
ATTN: Privacy Officer
GEHA
P.O. Box 21542
Eagan, MN 55121
FAX: 816.257.3283
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0I 91319 HIPAA COMPLAINT FORM About You This (GEHA)

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Completed 21 May 2021

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