pAMS STAFF ACCESS REQUEST form - CLINICAL

Patient Name *

First Name

Last Name

Date of Birth: (ex: Month, Day, Year: January, 01, 1990)

MM

DD

YYYY

Common Requests:

Ordering MRIs, labs, or diagnostic tests

Requesting medical or surgical clearances

Contacting another physician’s office for records or coordination

Booking a procedure

Scheduling a diagnostic test (e.g., EMG, imaging, cardiac testing)

Preparing or sending referrals

Coordinating follow-up appointments with specialists

Obtaining outside medical records

Something else