VitalChart® Virtual ROI Portal

Quick Release to You New Medical Records Request

Patient First Name

Patient Last Name

Patient Date of Birth

Requested Records:

Include visits from today or yesterday?

May delay processing by 2 days.

NOTE: Physical Therapy records are NOT available via this request.

Relationship to Patient

Name

Preferred Notification Method

Phone Number

Type

Retype Phone Number

Email Address

Retype Email Address

Delivery options will appear here once you've selected the records you'd like to receive.