VitalChart® Virtual ROI Portal

Release to Third-Party 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.

The following information will not be released unless specifically authorized by checking the relevant box(es) below:

Information pertaining to mental health diagnosis or treatment

Information pertaining to drug and alcohol abuse, diagnosis, or treatment

HIV/AIDS test results

Genetic testing information

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.

Recipient

Name

Address

Address Line 2

City

State

Zip

Phone or Fax Number

Phone Number

Phone Extension