	About Us		HIPAA and Privacy Policy		Breach of Privacy and/or Security Compliant Form

Breach form

Effective April 14, 2003, a complaint about a potential breach of privacy and/or security may be filed with PPO USA 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:

Email:
   privacyofficer@geha.com

Mail:
   PPO USA
   Attn: Privacy Officer
   310 NE Mulberry St.
   Lee's Summit, MO 64086

Fax:
816-257-3283

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. GEHA is the parent company of PPO USA Inc.

About You

First Name

Middle Initial

Last Name *

Do you reside within the United States?

Yes No

If YES, please enter your U.S. mailing address.

City *

State *

ZIP Code *

If NO, please enter your Overseas Address

Primary Phone Number

Alternate Phone Number

Email Address

Whose privacy was breached?

Member ID Number (if known) *

Member First Name (if known)

Member Middle Initial (if known)

Member Last Name (if known) *

Patient First Name (if known)

Patient Middle Initial (if known)

Patient Last Name (if known) *

What is the complaint?

Type of Complaint

Complaint Description

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Breach form