VitalChart® Virtual ROI Portal | UC Irvine Medical Center

Quick Release to You New Medical Records Request

Patient First Name

Patient Last Name

Other Patient Names (Optional)

Patient Date of Birth

Physician/Clinic (Optional)

Please select the visits/admissions you would like released:

Service Start:

Service End:

Please select the type of information you would like released:

Medical Records

Billing Statements

Please enter your reason for requesting records.Purpose:Limitations (Optional):

Relationship to Patient

Name

Address

Address Line 2

City

State

Zip

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.