Requesting Medical Records be sent to a non-CAMC facility/provider (CAMC / Teays visits)
This request form is to be used for visits to CAMC / Teays Valley locations. If you need records for
Greenbrier Valley Medical Center
or
Plateau Medical Center
, please use their request forms.
Patient Information
Patient Full Name
Patient's email address
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:
Patient's Phone # with Area Code
Provider Information
Which Provider Do You Want this Sent to Outside of CAMC:
First Name
Last Name
Provider's phone #
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)
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.
Contact Information
