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.

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

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

Request to Inspect and Copy Form : For requesting a copy of protected health information created and maintained by the GIC.

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

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.

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

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


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