Privacy

Request to Restrict Use and Disclosure of PHI

Use this form to request additional privacy safeguards to your health information if you are facing immediate danger, identity theft or fraud, or you have a specific privacy concern.

• Created: Dec 20, 2010
• Modified: Sep 15, 2023
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Authorization for Disclosure of Medical Information Form

This form enables a beneficiary to authorize Health Net Federal Services, LLC (HNFS) or its subcontractor to release his or her medical information to a specified third party, for example, a spouse, relative or law firm.

Please note: Incomplete and/or unsigned forms will not be processed.

You may fax this form to 1-844-308-8877 or mail it to:

TRICARE Legal Documents
PO Box 8818
Virginia Beach, VA 23450-8818

• Created: Aug 1, 2022
• Modified: Jun 6, 2018
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Request for Records

Use this form to request copies of beneficiary records maintained by Health Net Federal Services, LLC or its subcontractors.

• Created: May 14, 2013
• Modified: Sep 15, 2023
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Request to Amend Protected Health Information (PHI) Records

Use this form to request amendments or corrections to the PHI maintained by Health Net Federal Services, LLC (HNFS) or its subcontractors, if you feel the information inaccurate, incomplete or incorrect.

• Created: Sep 15, 2023
• Modified: Sep 15, 2023
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California Consumer Privacy Rights Request Form

Per the California Consumers Privacy Act (CCPA), this form may be used by California residents to request the following:

• accounting (report) of personal information collected, used or shared, 
• deletion of personal information or
• opt-out of the sale of personal information. 

We do not sell personal information for money; however, we may disclose personal information for business purposes to certain third parties. Subject to exceptions, we may be able to honor certain opt-out requests.

Return this form via fax or mail.

• Created: Aug 1, 2022
• Modified: May 31, 2022
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