Log in links for this page

GIC HIPAA Privacy Forms

Forms to enroll in and change your GIC health and other benefit coverage options

HIPAA Notice of Privacy Practices - Comprehensive list of GIC enrollee privacy rights.

HIPAA Amendment Form - For asking the GIC to amend erroneous or incomplete protected health information created and maintained by the GIC.

HIPAA Confidential Communication Form - For personal safety reasons, form to request alternative GIC communication delivery.

HIPAA Inspect and Copy Form - For requesting a copy of protected health information created and maintained by the GIC.

HIPAA Privacy Complaint Form - For lodging a complaint with the GIC on how the GIC handled your protected health information.

HIPAA Accounting of Protected Health Information Disclosure Form - For requesting an accounting of the GIC's disclosures of protected health information on or after April 14, 2003.

HIPAA Authorization for Release of Health Information Form - For authorizing GIC representatives to disclose or receive your protected health information with persons you designate.

HIPAA Restrict Access Form - For requesting to restrict the GIC's use or disclosure of protected health information.

HIPPA Information Release Form

Contact   for GIC HIPAA Privacy Forms



Fiscal (617) 367-9874


GIC Print Forms and Member Correspondence Mailing Address
PO Box 556, Randolph, MA 02368
Street Address
John W. McCormack Building, 1 Ashburton Place, Suite 1619, Boston, MA 02108

Help Us Improve Mass.gov  with your feedback

Please do not include personal or contact information.