8/5/19
PHI04/R12
ENR-1425-PHI04
GE-FRM-0119-006
0K
ACCESS REQUEST FORM
U
se this form to request that GEHA provide you with a copy of protected health information (“PHI”)
maintained within a designated record set by or on behalf of GEHA.
About you, the GEHA member whose PHI is requested
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
PHI To Be Released
Description of PHI Desired _____________________
Dates of Service from: to
Format: ___Paper Copy __Electronic Copy
___Summary of Requested Information __Inspection at GEHA
(a fee may be charged) (an appointment will be scheduled)
PHI to be released to: __Self __Other (Please fill in contact information below)
Mail to Name:
Mail to Address:
Email (if Electronic Copy Requested): _____________________________________________________________
• I understand that my request will be processed within 30 days. GEHA may take up to 30 additional days to fulfill the
request, but will inform me within 30 days of receipt of the request of the need for an extension.
• I understand that, under HIPAA, I have the right to inspect and/or obtain a copy of my PHI maintained in a designated
record set, unless otherwise prohibited by law.
• I understand that this request may be denied in whole or in part. If so, except as otherwise permitted under applicable
law, I have the right to request a review of this decision and understand that GEHA will communicate these rights in
the case it denies my request.
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
![]()
