Release of Medical Records OUT (2023)

Release of Medical Records (OUT)

Bloom Pediatrics • 2055 E 14 Mile Road, Birmingham, MI 48009 • (248) 645-1740
Use this form to transfer records FROM Bloom Pediatrics to 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
Releasing Records To

Please release the medical records from the office of Bloom Pediatrics and send to:
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.
I authorize the release of medical records obtained in this office.

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
Reasons for transferring:*

Moving (in state)Moving (out of state)Moving (out of country)Dissatisfied with officeOther
Dissatisfied with office - please explain:*
Records will be mailed to the assigned account holder or made available for pickup within 5 business days of the request.

A payment of $20 must be received for a copy of the patient's full medical record, prior to completing the request. A summery of care can be provided at no cost.
Please specify below what form of records you would like to receive:*

Summary of careFull medical record
Phone Number
Please enter a valid phone number.
Please charge the credit card on file*

No, I will call with a credit card numberYes, please change the credit card on file
Should be Empty:

Release of Medical Records (OUT)

Patients

Releasing Records To

I authorize the release of medical records obtained in this office.