Minnetonka Medical Release Patient InformationPatient Name(Required) Patient Birth Date(Required) Patient Address(Required) Patient City(Required) Patient State(Required) Patient Zip Code(Required) Patient Date of Injury(Required) Patient Date of Treatment(Required) Information to be Released to:Minnetonka Police Department, ATTN: 14600 Minnetonka BlvdMinnetonka, MN 55345Phone:Fax:Custodian of RecordsHospital Investigations recommends leaving this blank Hospital Address Investigations recommends leaving this blankHospital Telephone Investigations recommends leaving this blankInformation to be Released:All Certified Uncertified Medical records pertaining to the above-referenced incident date treatment date(s), including but not limited to: X-ray/Radiology Reports Photographs Discharge Summary Operative Reports ER Reports Consultation Reports Other Purpose: This Information is needed for the following purpose: Use in the investigation and prosecution of the cases(s)State of Minnesota v Case Number(s) Terms of Release (for patient signing)1. This authorization will automatically expire one year from the date of my signature. 2. This authorization may be revoked by written request of the patient at any time to the address listed for the requesting entity. A revocation will not apply to information that has already been released in response to this authorization. 3. Once information is released pursuant to this authorization, the information may be subject to re-disclosure by the recipient and may no longer be protected by the federal privacy rule, 45 CFR Parts 160 and 164.4. With the exception of psychotherapy notes, all records pertaining to psychiatric/mental health, chemical dependency and/or AIDS/HIV related illness/testing will be released unless otherwise indicated by a checkmark here: Please indicate any restrictions: (Specify) 5. This authorization must be filled out completely and signed and dated to be considered valid. 6. A copy of this authorization will be considered as valid as the original authorization. 7. Treatment, payment for services, enrollment and eligibility for benefits are not contingent upon signing of this authorization form.Patient's / Authorized Person's Signature:Signature of Patient / Authorized PersonDate of Signature MM slash DD slash YYYY Authorized Person’s Authority to Sign Reason Patient is unable to sign Minor Deceased Other Other Reason Officer Email(Required)