Breach of Privacy and/or Security Complaint Form

Effective April 14, 2003, a complaint about a potential breach of privacy and/or security may be filed with GEHA in regard to the privacy or security regulations of the Health Insurance Portability and Accountability Act (HIPAA). Please include as much information as possible regarding how you feel a breach may have occurred to assist us in reviewing the issue.

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


Mail: GEHA Attn: Privacy Officer P.O. Box 438 Independence, MO 64051-0438

This is a secured form. Please complete the appropriate information below as well as entering an explanation in the Question/Issue box and select submit to send this form by email to GEHA Compliance Department.

All fields are required unless marked as optional.

About You

Whose privacy was breached?

What is the complaint?

Please select the appropriate item in regard to the area of privacy and/or security that you feel has been breached.
In the comment box above, please provide the following information: Date(s) issue occurred; name(s) of individual(s) involved (if any); what occurred.