Forms for Patients

Sports Physical & Immunization Form

Sports Physicals and Vaccine Authorization

Information Release Forms

The forms below can be printed and filled out. You can return the form by fax, mail or by bringing it to our Health Information Management Department(HIM). The HIM department is located in the basement of Gabert Clinic across from the Carney Center. If bringing the form directly to the office, photo id is required. Behavioral Health records require specialized paperwork, in order to access those records please come to the HIM department.

Information Release Form

Request for Amendment Form

An individual has the right to request, in writing, that GMC amend their Protected Health Information (PHI). The Health Insurance Portability and Accountability Act (HIPAA) mandates that an individual has the right to request an amendment to their record if they feel there is incorrect or incomplete information maintained within the designated record set. To request an Amendment, please click on the Request for Amendment form below and submit it to the GMC Privacy Officer or Health Information Management (HIM) to process. The request must be completed in full, , including the reason to support the request for amendment. The Privacy Officer or HIM Manager may request a copy of the individuals photo ID, or other documentation as necessary, to confirm identity. GMC will act on the amendment requests within 60 days of receiving the initial written request.

Request for Amendment Form

Workers Compensation Form

The following form(s) can be printed and filled out and brought to your appointment at Gabert Clinic. The form(s) must be filled out for insurance purposes so filling them out in advance will cut down your registration time.

Workers Compensation Information Form