Release of Medical Records IN (2023)

Release of Medical Records (IN)

Bloom Pediatrics • 2055 E 14 Mile Road, Birmingham, MI 48009 • (248) 645-1740
Use this form to transfer records TO Bloom Pediatrics from another practice.
Patients

List the name and date of birth for each child in your family who is a patient.
How many children in the family are patients?
Patient 1 Name*
Patient 1 Date of Birth*

MonthDayYear
Date
Patient 2 Name
Patient 2 Date of Birth

MonthDayYear
Date
Patient 3 Name
Patient 3 Date of Birth

MonthDayYear
Date
Patient 4 Name
Patient 4 Date of Birth

MonthDayYear
Date
Patient 5 Name
Patient 5 Date of Birth

MonthDayYear
Date
Patient 6 Name
Patient 6 Date of Birth

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physican Releasing Records
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Releasing Records To

Bloom Pediatrics
2055 E 14 Mile Road
Birmingham, MI 48009

Phone: (248) 645-1740
Fax: (248) 645-5304

info@bloompediatricsmi.com
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
I authorize the following to be released via fax/email/mail (check all that apply):*

All records of care between the Start and End dates noted aboveProgress notes and physical exam notes for the past 12 monthsLab testsRadiology testsImmunization recordsOther
Authorization

Signature of Patient (if 18 years or older), Parent, or Guardian
Signature*

Clear
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date

MonthDayYear
Date
Should be Empty:

Release of Medical Records (IN)

Patients

Physican Releasing Records

Releasing Records To

Authorization