Requesting Medical Records be sent to a non-CAMC facility/provider (Plateau Medical Center visits)
This request form is to be used for visits to
Plateau Medical
Center
locations. If you need records for
CAMC / Teays Valley
or
Greenbrier Valley Medical Center
, please use their request forms.
Patient Information
Patient Full Name
Patient Date of Birth (month/day/year)
Last 4 digits of patient's SS#
Who is Completing This Request (Full Name)
If you are not the patient, what is your relationship:
Phone Number with Area Code
Provider Information
Which Provider Do You Want this Sent to Outside of CAMC:
What is the Fax Number for this Provider:
What records do you need us to send:
Labs
Radiology Reports
Office Visit Note
Operation Reports
Emergency Room Report
Other
Please specify the records you need sent
Please enter the visit date(s)
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Contact Information
