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.

  • 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
     - -

  • Releasing Records To

    Please release the medical records from the office of Bloom Pediatrics and send to:

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

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

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

  • Format: (000) 000-0000.
  • Date
     - -
  • Reasons for transferring:*

  • 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:*
  • Format: (000) 000-0000.
  • Please charge the credit card on file*
  • Should be Empty: