Form and Letter Request - GBCC Behavioral Health

Requesting forms or letters

Please allow a minimum 7-10 business days for a patient representative to contact you about this request.

Forms are completed during a patient appointment with few exceptions. Forms are only completed for ongoing, active patients and at provider discretion.

Forms completed outside of any appointment acure a fee not paid by insurance. Rate is $50 per 15 minute unit of provider time. Fees must be paid at the time of service.

**If you have a custom form that needs to be completed, PLEASE drop at office location OR email pdf or word document prior to appointment: formsrequest@gbcc.com

Patient First and Last Name(Required)

First Last

Your Email(Required)

Enter Email Confirm Email

Best phone # to reach you(Required)

Name of your Provider:

First Last

What are you requesting?

Form

Letter

Other

What else would you like us to know about this request?

Terms(Required)

By checking this box, you understand this request for a form/letter will be granted at the discretion of the provider and that you may contacted to schedule an appointment if needed before the request can be completed.

This field is for validation purposes and should be left unchanged.