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Choose any of the following materials for download to your computer in Adobe Acrobat format. To read these files, you'll need a copy of the free Adobe Acrobat Reader®.

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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.