Medical Records Request Form To request a copy of your Hazelden Betty Ford Foundation patient medical record, download and print the Medical Record Release Form. Complete, sign, mail, email or fax the Medical Release Form to us at: Hazelden Betty Ford Foundation 15251 Pleasant Valley Road P.O. Box 11, BC 22 Center City, MN 55012-0011 Fax: 1-651-213-4496 Email: HealthInformation@hazeldenbettyford.org When filling out the Medical Record Release Form, be sure to indicate who your medical record should be sent to in the appropriate space on the form. *As of March 21, 2017, all medical record releases must be made out specifically to an individual unless they are an entity with a treating provider relationship with the patient or a third-party payer per 42 CFR Part 2, Section 2.31. Average processing time The average processing time to complete medical records requests is 3-5 business days (M-F). The time it takes to receive your medical record will vary with delivery method. Follow-up calls to confirm request receipt Allow 2 business days from request date to ensure the request has been received and entered into our system. Questions? Contact our Health Information Department at 1-651-213-4492. Financial Information Request Form 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, download and print the Financial Release Form. Once printed, complete, sign and mail or fax the Financial Release Form to: Hazelden Betty Ford Foundation Patient Accounts, RW 18 P.O. Box 11 Center City, MN 55012-0011 Fax: 1-651-213-4543 Questions? Contact our Patient Accounts Department at 1-651-213-4267.