Welcome to Bloomington Pediatrics

Forms

welcome to form central!

Below you will find our standard registration and release of medical records forms.

If the form you need completed for your child is not listed below, let us know! We have most forms required for schools and daycares, but are happy to complete forms that you provide to us.

Plan ahead and bring the form with you to your child's well visit or call us in advance to see if it is one we have on hand!

A few things to keep in mind:

Please allow 24-48 hours for us to complete your form request. On occasion, it may take longer if your provider is not in the office. We aim for a speedy turn around and appreciate your patience!
Parents are required to complete the "parent sections" of forms regarding patient demographic data, insurance, etc. Our nursing staff and providers will take care of the "medical sections."
Completed forms may be picked up in person (valid photo ID required), sent via the patient portal, or snail-mailed. We are not able to email forms, nor are we able to fax them to schools or daycares.

*Pro-Tip from a BloomingtonPeds Nurse-Mom: Make a copy of your completed form for your own personal file, so if "Coach" misplaces it, you have a backup copy on hand and don't have to wait for a new one! You can also ask for your completed form to be sent through the patient portal so you may print a new copy as needed.

New Patient Packet

Patient Registration Form

Online Form PDF Form

Complete this form to provide new patient demographic information, insurance, consent for us to treat your child and consent for another adult (other than parent or legal guardian) to accompany your child to their appointment.

Notice of Privacy Practices (HIPAA)

PDF Form

Click on the PDF to view our HIPAA Privacy Policies.

HIPAA Acknowledgement Form

Online Form PDF Form

Complete the acknowledgement of receipt and understanding of our HIPAA Privacy Policies.

Lactation Moms Registration

Lactation Mom Information Sheet

Online Form PDF Form

Complete this form to provide new patient demographic information, insurance, consent for us to treat you as a mom seeking consultation with our lactation specialist

Notice of Privacy Practices (HIPAA)

PDF Form

Click on the PDF to view our HIPAA Privacy Policies.

HIPAA Acknowledgement Form

Online Form PDF Form

Complete the acknowledgement of receipt and understanding of our HIPAA Privacy Policies.

Established Patient Forms

Patient Information Sheet

Online Form PDF Form

Complete this form to update demographic information, insurance, consent for us to treat your child and consent for another adult (other than parent or legal guardian) to accompany your child to their appointment.

Notice of Privacy Practices (HIPAA)

PDF Form

Click on the PDF to view our HIPAA Privacy Policies

Acknowledgement of Notice of Privacy Practices

Online Form PDF Form

Complete this form to acknowledge receipt and understanding of our HIPAA Privacy Policies

Update Consent for Treatment / Financial Responsibility

Online Form PDF Form

Complete this form to confirm insurance and responsible party on the patient account, as well as update who is able to call for information, bring your child in for an appointment, consent to treatment, and / or pickup documents and prescriptions.

Release of Information Forms

Medical Records Release Form

Online Form PDF Form

Complete this form if you are transferring your medical records

Consent to Treat an Unaccompanied Minor

Online Form PDF Form

Complete this consent form for your child aged 16-17 who wishes to attend their appointment alone.

Under 18 Release of Information

Online Form PDF Form

Choose this option for the parent or legal guardian to consent to another family member or adult to have access to your under age 18 child's patient information

Age 18 and Up Release of Information

Online Form PDF Form

Patients over the age of 18 must complete this release to allow a parent, legal guardian or other adult to have access to their patient information

Patient Screening Tools

Adolescent Depression Screening

Online Form PDF Form

Heart Health Questionnaire for Young Athletes

Online Form PDF Form

Edinburgh Postnatal DepressionScale

Online Form PDF Form

MCHAT-R

Online Form PDF Form

Vanderbilt ADHD Parent Questionnaire

PDF Form

Vanderbilt ADHD Teacher Questionnaire

PDF Form

Vanderbilt ADHD Parent Questionnaire - (Spanish)

PDF Form

Vanderbilt ADHD Teacher Questionnaire - (Spanish)

PDF Form

IF YOU HAVE AN ILL CHILD OR URGENT REQUEST, PLEASE DO NOT USE THIS FORM - CALL THE OFFICE DIRECTLY AT 309-662-0504 AND SELECT OPTION 1 FOR THE NURSE.

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This form is for General Inquiries Only. This email is only monitored periodically during regular M-F business hours.

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