VitalChart® Virtual ROI Portal | Michigan Medicine U of M

Patient Information

Patient First Name

Patient Last Name

Other Patient Names (Optional)

Patient Date of Birth

Patient Phone Number

Retype Phone Number

Physician/Clinic (Optional)

Please select the visits/admissions you would like released:

Most recentAllIn a date range

Package selections (as recommended in section 4, more may be specified below:

Package 1 Key Clinical

Written documentation (includes, as applicable, history and physical, discharge summary, operative reports, consults, outpatient visit notes, test reports ER clinical notes) related to a specific incident, injury or illness from Service Dates list above. If no dates listed, for the past 24 months.

Package 2 All Clinical

Written documentation from Service Dates listed above (includes, as applicable, **Package 1 contents along with all nursing notes, flow sheets, medication administration records, physician orders, etc..)

Other Records (check to specify)

Billing Records

Radiology Images (only)

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

Sexually Transmitted Diseases

Purpose of Request

Please enter your reason for requesting records.Purpose:

Your Information

Requestor Name

Preferred Notification Method

Phone Number

Type

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Fax Number

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Email Address

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Address

Address Line 2

City

State

Zip

Delivery Information

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

Delivery Summary

Normal processing time is 14 business days from time of receipt.
Please contact us if you have any questions.

New Medical Records Request

Patient Information

Purpose of Request

Your Information

Delivery Information

Delivery Summary