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Privacy Complaint Form

This form is for use in reporting any privacy or HIPAA compliance concerns to GEHA's Privacy Office.

Attachments must be sent under separate cover and will not be secured. If you need to send an attachment, please send to:

• Email: privacy@geha.com

• Mail: ATTN: Privacy Officer, GEHA, P.O. Box 21542, Eagan, MN 55121

About You

A member of the Privacy Office will contact you to confirm receipt of your complaint and gather any additional information needed for review. The Privacy Office will follow-up at the end of our review, using this contact information.

Does your complaint involve the private information of an individual employee or GEHA member? If so, please complete this section with as much information as is known.

Please select the applicable plan below, if known:

What is your concern