8/5/19
PHI06/R12
ENR-1445-PHI06
GE-FRM-0119-003
0K
REQUEST FOR AMENDMENT OF PROTECTED HEALTH INFORMATION (“PHI”)
Use this form to request that GEHA amend the PHI or record about you.
About you, the GEHA member whose PHI is to be amended
Plan ID Number:
Member Name: Date of Birth: _______________________
Address:
Telephone Number:
Please place a check mark in front of each plan you want this Amendment request to be applied:
___ GEHA Health Plan ___GEHA Connection Dental Federal Plan
___ Connection Dental Plus Plan ___CONNECTION Vision Plan
Information You Would Like Amended
Description of Amendment Requested
Dates of Service from: to
ATTACH COPY OF ALL INFORMATION (i.e. claim, records, etc.) TO BE CONSIDERED FOR AMENDMENT.
Individual(s) I Would Like Notified if Amendment is Accepted:
Name(s):
Address(es):
Signature and Acknowledgement
• I understand that my request will be processed within 60 days. GEHA may take up to 30 additional days to fulfill
the request, but will inform me within 60 days of receipt of the request of the need for an extension.
• I understand that this request may be denied in whole or in part. If so, I have the right to submit a statement of
disagreement 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, medical 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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