West Region

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

TRICARE West Region Privacy Office 

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 Health Net or the designated record set maintained for Health Net 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 Health Net designated record set or the designated records set maintained for Health Net 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 Health Net policies and procedures. The employees of Health Net 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 Health Net 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 Health Net 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.