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West Privacy Forms

Each of the privacy forms below can be mailed or faxed to the TRICARE West Region Privacy Office:

UnitedHealthcare Military & Veterans
TRICARE West Region Privacy Office
P.O. Box 105661
Atlanta, GA  30348-5661

Fax: 1-877-894-1493

Access Request

This form is for use by the TRICARE beneficiary or the beneficiary’s authorized representative to request access to inspect and/or to obtain a copy of the beneficiary’s protected health information (PHI) contained in the designated record set maintained by UnitedHealthcare or the designated record set maintained for UnitedHealthcare by one of its business associates. 

Amendment Request

This form is used by the TRICARE Beneficiary or the beneficiary's authorized representative to request the amendment of PHI in the UnitedHealthcare designated record set or the designated records set maintained for UnitedHealthcare by one of its business associates.

Authorization to Disclose Information

This Authorization to Disclose form is filled out when you, the beneficiary, want to grant another individual or organization access to your PHI. Your PHI is protected by the Privacy Act, the Health Insurance Portability and Accountability Act (HIPAA), state laws, and UnitedHealthcare policies and procedures. The employees of UnitedHealthcare Military & Veterans are trained to protect your information. 

Disclosure Accounting Request

This form is for use by the TRICARE beneficiary or the beneficiary’s authorized representative to document the beneficiary’s request for an accounting of disclosures of his/her PHI.   

Privacy Inquiry/Complaint Form

This form is for the use by a TRICARE beneficiary to submit an inquiry or complaint about TRICARE or UnitedHealthcare HIPAA Privacy policies or practices.  

Restriction Request

This form is for use by beneficiaries or their authorized representative to request that a restriction be placed on the use and disclosure of the beneficiary’s PHI.

Request for Confidential Communications

This form is for use by a TRICARE beneficiary or the beneficiary’s authorized representative to request that UnitedHealthcare use alternative means or an alternative address for the, communication of the beneficiary’s PHI in the event that sending communications to the address of record could endanger the beneficiary.

Last Updated 9/3/2013