Professional Documents
Culture Documents
2022-08-10-Health Lien Rawlings-Michelle Jordan
2022-08-10-Health Lien Rawlings-Michelle Jordan
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
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.
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:
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.
Michelle Jordan
SIGNATURE: Michelle Jordan (Jul 13, 2022 11:23 PDT) DATE: 07/13/2022