You may download a PDF version of the form here. You will need to print the form, complete all appropriate areas, sign and date.
You may fax the completed form to: Health Information Management at 218-643-0866
You may mail the form to:
Health Information Management
St. Francis Healthcare Campus
2400 St. Francis Drive
Breckenridge, MN 56520
Please contact the Health Information Management Department with any questions or comments you may have regarding your health information or medical record.
BIRTH CERTIFICATE REQUEST
To request a certified copy of a birth certificate, please contact:
Minnesota Department of Health
Attention: Office of the State Registrar/ Birth Certificates
P.O. Box 64882
St. Paul, Minnesota 55164-0882