Medical Record Release Form - Hazelden Betty Ford Foundation 2026

1. Click ‘Get Form’ to open the Medical Record Release Form in the editor.
2. Begin by entering your Patient Name and Birthdate at the top of the form. If you have other names used during treatment, please include them as well.
3. Select your preferred method of release by checking one of the options: Mail, Fax, or Flash drive. Specify the facility from which you are requesting records.
4. Fill in the approximate date of your treatment if known, and provide details about who will receive the information by filling in their Name, Attention, Address, Phone, Fax, and Email Address.
5. Indicate why you need this information by checking all applicable reasons such as Personal, Insurance, Legal, etc. Then select all types of information you wish to disclose.
6. Review the confidentiality statements and sign at the bottom of the form. Ensure that all required signatures are included before submitting.

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