VitalChart® Virtual ROI Portal

Patient Information

Patient First Name

Patient Last Name

Patient Date of Birth

Requested Information

All medical records will be provided

Include visits from today or yesterday?

May delay processing by 2 days.

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

Your Information

Relationship to Patient

Name

Preferred Notification Method

Phone Number

Type

Retype Phone Number

Email Address

Retype Email Address

Delivery Information

All records will be delivered via this website in Adobe PDF format. A notification will be sent when the records are ready for download, and they will be available for 30 days.

Recipient

Name

Attention

Address

Address Line 2

City

State

Zip

Phone or Fax Number

Phone Number

Phone Extension

Delivery Summary

All records will be delivered via this website in Adobe PDF format. A notification will be sent when the records are ready for download, and they will be available for 30 days.
Normal processing time is 5-7 business days from time of receipt.
Please contact us if you have any questions.

Release to Third-Party New Medical Records Request

Patient Information

Requested Information

Your Information

Delivery Information

Delivery Summary