Medical Record Release and Financial Information Request Forms

Financial
To request the release of your financial information and any other pertinent information to insurance, managed care, review agencies or others involved with your funding arrangements to bill, file claims, support the claims or other communication relating to funding for your treatment at Hazelden Betty Ford, please download the form. Once printed, complete, sign and mail or fax the Financial Release Form to the appropriate location found below.

Click here to download a
Financial Release Form

Hazelden Betty Ford Foundation
Patient Accounts, RW 18
P.O. Box 11
Center City, MN 55012-0011
Fax: 1-651-213-4543

Betty Ford Center
Health Information Department
39000 Bob Hope Drive
Rancho Mirage, CA 92270
Fax: 1-760-773-4180

Questions? Contact our Patient Accounts Department at 651-213-4345.
Medical Record
To request a copy of your medical record, download the form. Once printed, please complete, sign and mail or fax the Medical Release Form back to us.

Click here to download a
Medical Record Release Form

When filling out the form, be sure to indicate who (e.g.  yourself, attorney, probation officer, treatment center, etc.) your medical record should be sent to in the appropriate space on the form and what information you would like sent.

Please mail or fax the Medical Record Release Form to the appropriate location. Locations and fax numbers can be found below or at the bottom of the release form.

Betty Ford Center in Rancho Mirage or West Los Angeles, California

Betty Ford Center
39000 Bob Hope Dr  
Rancho Mirage, CA 92270-1375
Fax: 1-760-773-4180
Hazelden in Beaverton, Oregon

Hazelden Betty Ford Foundation
6600 SW 105th Ave., Suite 120
Beaverton, OR 97008
Fax: 1-503-641-5179

Hazelden, Springbrook Campus in Newberg, Oregon

Hazelden Betty Ford Foundation
1901 Esther Street  
Newberg, OR 97132-9529
Fax: 1-503-537-7007
Hazelden (all other locations)

Hazelden Betty  Ford Foundation
15251 Pleasant Valley Rd
P.O. Box 11, BC 22
Center City, MN 55012-0011
Fax: 1-651-213-4496


Questions? Contact our Health Information Department at 1-651-213-4492.