Instructions

Complete this form once for each family or household. It contains the following sections:

1. Patients
2. Release of Medical Records
3. Insurance
4. Family Demographics
5. Family Medical History
6. Patient Portal
7. Notice of Privacy Practices
8. Authorization for Other Caregivers

You will need your insurance card(s) and the subscriber's photo ID.

Physican Releasing Records

Releasing Records To

Bloom Pediatrics
2055 E 14 Mile Road
Birmingham, MI 48009

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

info@bloompediatricsmi.com

Authorization

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

Primary Insurance

Medicaid

Insurance Authorization and Assignment (Please Read and Sign)

I attest that the information I have given here is correct and true to the best of my knowledge. I hereby assign benefits to be paid directly to the doctor, and authorize him/her to furnish information regarding my visits to my insurance carrier. I understand that I am responsible for my entire bill unless this form is complete.

Please list all other individuals living in the child’s home, who are not patients.

Does your child or any of your child's biological parents, siblings, or grandparents have the following conditions for which they are followed by a doctor or treated with medications regularly? Please check all that apply.

Patient Portal Access

Access to records is available for all children under 18 years of age. When a patient turns 18 years old in the State of Michigan, by law, their record automatically becomes private. They may grant permission to a parent or guardian to access their chart by signing an additional release form.

Please list the name and email of the parent/guardian that would like access to the patient portal.

Bloom Pediatrics providers and staff are governed by and comply with the federal Health Insurance Portability and Accountability Act (HIPAA). We are required to abide by the terms of our office Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at the time. A copy of our current HIPAA statement is available upon request.

Patients age 18 and older are required to sign a waiver authorizing parental access to their account. Parents of patients over the age of 18 will not be permitted to access any medical or billing information without written consent of patient.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.  We are also required to abide by the terms of the notice currently in effect.  If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.  

Please sign the “Acknowledgement” below to acknowledge that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices. 

Acknowledgement

I have read the above HIPAA Privacy Policies. As indicated above, I know my rights as a parent or as a patient over the age of 18, and also know and agree to the policies and procedures set in place by Bloom Pediatrics.