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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:


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


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
Whose privacy was breached?
What is the complaint?