VitalChart® Virtual ROI Portal

Patient Information

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:

Emergency Room Visit

(i.e. ED provider notes, radiology reports, lab and diagnostic, consults and procedure notes)

Entire Hospital Record

(i.e. History and physical, consult, operative report, discharge summary, lab, radiology reports, nursing notes, progress notes)

Clinic or Office Visit

(i.e. Progress notes, office notes, procedure notes, operative notes, lab, diagnostic and radiology reports)

Billing Records

Radiology Images (only)

Reproductive Health (family planning , infertility)

Other Records

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

Psychological/Vocational Results

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

HIV/AIDS test results

Genetic testing information

Worker's Comp information

Purpose of Request

Please enter your reason for requesting records.Purpose:

Your Information

Relationship to Patient

Name

Preferred Notification Method

Phone Number

Type

Retype Phone Number

Email Address

Retype Email Address

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