Phone: (760) 633-2233

Fax: (760) 454-0915

Email: Liam@perrypi.com
Website: www.perrypi.com
Mail: 8605 Santa Monica Blvd. #90793
West Hollywood, CA 90069

August 5, 2022

SENT VIA FACSIMILE ONLY TO (502)753-7064

The Rawlings Company, LLC

PO Box 2000
La Grange, KY 40031

RE: Our Client: Leticia Gonzalez

Your Client: Kaiser Permanente
MRN: 23572223
Client DOB: December 25, 1982
Date of Loss: May 6, 2022

To Whom It May Concern,

Please be advised that this office represents Leticia Gonzalez in her personal injury
claim for an auto collision that occurred on May 6, 2022. This letter is to request an
itemized lien for the above referenced accident.

Attached is our client’s signed medical authorization.

Please fax the itemized lien to (760)454-0915 or email to Erica@perrypi.com. Thank

you very much for your anticipated cooperation and prompt response.

Very truly yours,

Liam R. Perry
PERRY LAW, Inc.

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 Phone: (760) 633-2233
Fax: (760) 454-0915
Email: Liam@perrypi.com
Website: www.perrypi.com
Mail: 8605 Santa Monica Blvd. #90793
West Hollywood, CA 90069

CLAIMANT’S DESIGNATION OF ATTORNEY

I, Letrica Gonzalez, hereby designate Perry Law, Inc. to act as my duly authorized and
designated attorney to handle any and all claims for property damage, bodily injury, or any
type of damages whatsoever arising out of the accident of May 6, 2022.

I also give my approval for the release of all police reports/records, arrest records, jail/prison
records, and probation reports/records, and any and all employment, payroll, education, or job
training records as may be deemed necessary by my legal representatives.

Signed this day, May 26, 2022.

Leticia Gonzalez (Jun 9, 2022 12:41 PDT)

Signature

Letrica Gonzalez
Print Name

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 Phone: (760) 633-2233
Fax: (760) 454-0915
Email: Liam@perrypi.com
Website: www.perrypi.com
Mail: 8605 Santa Monica Blvd. #90793
West Hollywood, CA 90069

FOR THE RELEASE OF HEALTH-RELATED INFORMATION

(HIPAA – COMPLIANT FORM)

Individual: Letrica Gonzalez

Date of Birth: 12/25/1982 Date of Loss: 05/06/2022

Social Sec No: AKA:

At the request of the individual, you are hereby authorized to release the protected health
information as directed below.

Description of Information: This release applies to all documents, records reports, x-rays or
other films. Photographs, billings studies, or correspondence relating to the treatment,
examination, or hospitalization including but not limited to all physical or psychiatric
conditions. This includes information on the diagnosis or treatment of human
immunodeficiency virus (HIV) infections. This also includes information of diagnosis of
treatment of mental illness and the use of alcohol and drugs unless otherwise listed below.

I also give my approval for the release of all police reports/records, arrest records, jail/prison
records, and probation reports/records, any and all employment, payroll, education, or job
training records as may be deemed necessary by my legal representatives.

Non-Releasable Information:

This authorization applies to all records both prior to and after the date of signature unless
specified. Nothing shall be removed, detailed, altered or withheld.

Disclosing Entity/Facility: The Rawlings Company

Recipient of Information: The individual or the individual’s legal representative designates

Perry Law, Inc., as their agent to pursue any and all information as directed above.

Purpose: At the request of this individual, the information sought is for the specific use of said
person or law firm in representing the individual authorizing this release for claims relating to
their injuries, benefits or other related matters.

This document covers information or material whose disclosure would otherwise be prohibited
by state or federal statutes or regulation, including but not limited to, all HIPAA rules and
regulations.

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Duration: This authorization shall become effective immediately and shall remain in effect for
one year from the date of signature.

Right to Revoke: The individual has the right to revoke this authorization at any time during
which this authorization is in force by giving written notice of revocation to Perry Law, Inc.
The person signing this authorization has a right to receive a copy hereof, and a reproduced
copy of this authorization shall be as valid as the original.

No Conditions: I understand that I may refuse to sign this authorization and that my refusal
to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits.

Re-disclosure: I understand that the information used or disclosed may be subject to re-
disclosure by the person(s) or class of person(s) receiving it and is no longer protected by the
federal privacy regulations pursuant to the Evidence Code, Code of Civil Procedure, Labor
Code or any other State of California Code Sections relative to the issues regarding the copying
of my records.

SIGNATURE: Leticia Gonzalez (Jun 9, 2022 12:41 PDT) DATE: 05/26/2022