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Forms

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  • Authorization Form – State of Texas Dental Choice Plan members and dependents may use this form to allow GEHA to disclose protected health information to a designated person.


  • Revocation of Authorization Form – State of Texas Dental Choice Plan members and dependents may use this form to revoke or remove an authorization for disclosure of protected health information.


  • Confidential Communications Form – State of Texas Dental Choice Plan members and dependents may use this form to make a reasonable request to receive communications by an alternative means or at an alternative location, if disclosure of all or part of that information could endanger the individual.


  • Revocation of Confidential Communications Form – State of Texas Dental Choice Plan members and dependents may use this form to revoke or remove a previously accepted confidential communication.


  • Request for Restriction Form – State of Texas Dental Choice Plan members and dependents may use this form to request restriction of their protected health information from disclosure to a specified person(s).


  • Revocation of Restriction Form – State of Texas Dental Choice Plan members and dependents may use this form to revoke or remove a previously accepted restriction of their protected health information from disclosure to a specified person(s).


  • Access Form – State of Texas Dental Choice Plan members and dependents may use this form to request copies of health information.


  • Accounting of Disclosures Form – State of Texas Dental Choice Plan members and dependents may use this form to request an accounting of disclosures regarding their protected health information.


  • Amendment Form – State of Texas Dental Choice Plan members and dependents may use this form to request an amendment of their protected health information.


  • Privacy Complaint Form – This form may be used by anyone to report a breach of privacy in regard to the State of Texas Dental Choice Plan.
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