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.

  • Patient 1 Date of Birth*
     - -
  • Patient 2 Date of Birth
     - -
  • Patient 3 Date of Birth
     - -
  • Patient 4 Date of Birth
     - -
  • Patient 5 Date of Birth
     - -
  • Patient 6 Date of Birth
     - -

  • Physican Releasing Records

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

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

  • Authorization

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

  • Format: (000) 000-0000.
  • Date
     - -
  • Should be Empty: