Patient Forms

During your visit, your Provider will determine if you need DME. Most DME requires insurance. If you do not have insurance, you will be responsible for the cost. Repairs also require a visit with your provider. Call 1-888-296-GPHA (4742) to schedule an appointment.

The Employment Physical Form requires a visit with a provider. Please bring your Employment Physical Form with you to your visit. Call 1-888-296-GPHA (4742) to schedule an appointment.

The FMLA form requires a visit with a provider. GPHA supports the completion of FMLA Form(s) for our established patients only. Please bring your FMLA Form with you to your visit.. Call 1-888-296-GPHA (4742) to schedule an appointment.

GPHA provides support for Handicap Placard Forms. You must be an established GPHA patient with documentation of a disability in your medical record. At the discretion of the patient’s provider, the Handicap Placard form may be completed for your caregiver. Please bring the Handicap Placard Form with you to your visit. Call 1-888-296-GPHA (4742) to schedule an appointment.

GPHA provides support for License Plate Forms. You must be an established GPHA patient with documentation of a disability in your medical record. The Handicap License Plate Form can be completed for the patient only. Please bring the Handicap License Plate Form with you to your visit.. Call 1-888-296-GPHA (4742) to schedule an appointment.

GPHA provides support for Handicap Parking Space Forms. You must be an established GPHA patient with documentation of a disability in your medical record. The Handicap Parking Space Form will be completed for the patient only. Please bring the Handicap Parking Space Form with you to your visit. Call 1-888-296-GPHA (4742) to schedule an appointment.

There are three (3) ways to request a copy of your Medical Records:

1. At a health center, fill out a record request form. You will need to have photo ID with you.
2. In the Patient Portal, request that your records be uploaded to your Patient Portal account. Be sure you have created Patient Portal account first.
3. You can fill out a medical record request form with another health care provider, attorney, or third party. Once we receive and process the request, your records will be sent to the requesting party.

GPHA provides support for established patients who need Home Health Aid services. These services must be ordered by your medical provider. Call 1-888-296-GPHA (4742) to schedule an appointment.

GPHA supports patients with medical necessity for limited home renovations such as grab bars or lowering of cabinets. An office visit is required. Please bring the form to your office visit. Call 1-888-296-GPHA (4742) to schedule an appointment.

GPHA supports transportation needs of patients with documented medical necessity. If you have a specific transportation form, please bring it with you to your next visit. Call 1-888-296-GPHA (4742) to schedule an appointment.

This form requires a visit with your provider. If you have a specific Medical Assessment Form that you need to have completed, please bring it with you to your visit. Call 1-888-296-GPHA (4742) to schedule an appointment.

This form requires a visit with a Registered Dietician and a prescription from your provider. Please call to schedule an appointment with a GPHA dietician and bring the form with you. Call 1-888-296-GPHA (4742) to schedule an appointment.

Your provider will order these services and complete any required documentation for Skilled Nursing Services. Call 1-888-296-GPHA (4742) to schedule an appointment.

GPHA provides support for an oxygen qualification assessment. This assessment requires a visit. Please call to schedule an appointment. Call 1-888-296-GPHA (4742) to schedule an appointment.

A visit with your provider is required to establish the presence of a chronic condition(s). Please call to schedule an appointment and bring any utility forms with you. Call 1-888-296-GPHA (4742) to schedule an appointment.

A sports physical requires an office visit. GPHA will provide a form and attach your vaccine record. Please call to schedule an appointment. Call 1-888-296-GPHA (4742) to schedule an appointment.

Your provider can refer you to Physical Medicine and Rehabilitation (Physiatry) for a mobility assessment. Call 1-888-296-GPHA (4742) to schedule an appointment.

This form requires an office visit at least 14 – 30 working days before the date of surgery to allow for review of your lab work and communication with your surgeon. If your surgery clearance cannot be completed in time, you surgery may be cancelled or rescheduled. If you have a surgical clearance form, please schedule an office visit with your provider at least 1 – 2 months in advance of your scheduled surgery. Call 1-888-296-GPHA (4742) to schedule an appointment.

GPHA providers are authorized to provide surgical clearance for patients having procedures in the Delaware Valley (Southeastern PA, South Jersey, or Northern Delaware).  If the procedure is being performed outside this geographic area, however, GPHA providers are not authorized to perform a pre-operative evaluation.

GPHA does not provide support for the completion of CDL forms.

For more information on how to obtain a Commercial Driver’s License, go to: Commercial Driver’s License Program | FMCSA (dot.gov)

Please contact the Medical Records Department so that a copy of your chart can be sent to the Social Security Administration.

For medical marijuana services in PA, you must see a certified provider. For more information, go to: https://www.health.pa.gov/topics/programs/Medical%20Marijuana/Pages/Medical%20Marijuana.aspx

For assistance with military eligibility and healthcare assessments, please contact the appropriate branch of the US Armed Services.