Medical Records Request

In order to send a Medical Records Request to our Health Information Management (HIM) Department, please complete the submission form below. One of our team members will follow up with you directly. If you have an urgent request, or need to speak with someone, please call us at 540.316.4444.

Patient Authorization for Disclosure Form

In order to complete a Medical Records Request, the patient or authorized representative may be required to complete a patient authorization for disclosure form.

ENGLISH Request Form SPANISH Request Form

Sending a Medical Records Request

First Name

Last Name

Phone Number

Email Address

Message

DISCLAIMER NOTICE. I understand that I am sending personally identifiable information through email.I Understand and Agree.