8/5/19
1
PHI05/R13
ENR-1435-PHI05
GE-FRM-0119-004
0K
REQUEST FOR ACCOUNTING OF DISCLOSURES OF
PROTECTED HEALTH INFORMATION (“PHI”)
Use this form to request that GEHA provide you with documentation of disclosures of your PHI
made by GEHA.
About You, the GEHA member whose information 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 Accounting of Disclosure request to be applied:
___ GEHA Health Plan ___GEHA Connection Dental Federal Plan
___ Connection Dental Plus Plan ___CONNECTION Vision Plan
Accounting Request
I request an accounting of how my PHI was disclosed by GEHA or a Business Associate of GEHA as required by
federal regulations.
I want an accounting of disclosures that covers the following time period:
Please send my accounting to the following address:
Signature and Acknowledgement
I understand that GEHA does not have to tell me about the following types of disclosures:
• Disclosures for purposes of treatment, payment, and healthcare operations;
• Disclosures to me, my personal representative, or authorized by me;
• Disclosures to persons involved in my care;
• For national security or intelligence purposes, to correctional institutions, or to law enforcement officials under
certain circumstances;
• As part of a limited data set when the recipient has executed a data use agreement; and
• Disclosures incident to a use or disclosures otherwise permitted or required by law.
I also understand that my right to an accounting or some or all disclosures may be suspended by the government under
limited circumstances.
