Release of Information
& Disability Forms
Portal

Requestor Login

Acct No
PIN
By clicking this box, you accept VitalChart Release of Information Terms of Service and agree to be bound by them.
Where to find your Acct No. and PIN

If you have payment questions, call the Provider or call Service Company listed on the ROI Notification or Invoice.

This site is for authorized use only and all usage may be monitored and/or recorded. Users of this site represent that they are authorized and expressly consent to such monitoring and/or recording. Users of this site are advised that any fraudulent attempts to access entry will be shared with law enforcement officials.

Provider Login

Acct No
Username
Password

For support issues, please refer to the Contact information contained in both the Fulfillment Notice and the Invoice that you will receive by fax once the request has been completed.

ROI Plus

YOUR OFFICE HAS REQUESTED A PHI FOR THE PATIENT LISTED BELOW

PHI REQUEST FULFILLMENT NOTIFICATION Sample Bar Code
REQ2013062000444427238

Request Date:		Request ID:
Requestor Name:		Patient Name:
Requestor Acct:	R11111	Patient DOB:
Requestor PIN:	0542	Patient MRN:

Invoice

Remit To:

Invoice Number

Invoice Date

Provider Acct No.

Bill To

Requestor Acct No.

Requestor Date

R11111

Requestor PIN

Requestor ID

0542

Patient Name

Patient DOB

Release of Information& Disability FormsPortal

Requestor Login

Provider Login

Release of Information
& Disability Forms
Portal