01182024-4City of Anaheim
Attn: Records Department
200 S. Anaheim Blvd.
Anaheim, CA 92805
Patient:
Patient DOB:
Patient SSN:
DOS:
Dear Sir or Madame:
January 15, 2024
Pedro R. F,scobcdo
March 18, 2023
This office has been retained to represent the interests of Pedro R. Escobedo in connection with
physical injuries he sustained in an accident that occurred on March 17, 2023. Enclosed please
find a medical authorization form signed by Mr. l".scobedo which we are submitting for purposes
of obtaining a copy of your ambulance records and billings on this patient. If you would be so
kind, please provide our office the requested material by forwarding same to my attention at the
above -stated address.
If there is a charge for reproducing any of the material requested, please include an invoice for
said charges at the time the records are produced so that we may insure you are promptly
reimbursed.
Thank you for your courtesy and cooperation in this matter. Should you have any questions or
comments concerning same, please 1ccl free to call me.
Very truly yours,
Mark W.
Attorney
Authorizatioii Foi-m)
I II PPA CO P1,1AN` ' M E� 1)1C'AL AUT110RI%ATI0N
1. Pedro I:sccahedcl. herehy aautliorirc you. as my treating physician and/or healthcare
provide-, to release to the. Fisenlier4g Law Firm its agents and representatives, the cariginals, or
le.!ihle copies therccrl, ol'any and ,all medical records medical billings and radiographic studies
concerning any and all care and trcaatincnt provided Inc: at anytime within the ten (10) year period
prior to the execution of this medical authorization. Those records that should be produced
include, but are not limited to, sirr-in sheets. patient in -talc: Corms, patient yuestionnaircs, Iaursc:s
Iaca m progress notes SOAP notes. disability reports/letters, referral loans, prescriptions,
radiographic studies and reports,
I Curther aauthorize you as nro, trcatim, physician and/or healthcare provider. to speak
dircetly with my attorneys about mv presenting condition. symptoms, diaaonosis. care and
treatment, p1,0110sis and need li r linther and/car additional care. if`called Upon Iry them,
That authorization shall lie valid liar a period of` I -year From the date set forth below, I
Understand that I may revoke this Authorization at anytime. My reVOCaatiOrI Ia7alst he in writing
and will be cf'fectivc upon your receipt. but will not he efl' cti e to the extent that the I2ecluestcar
or others have acted in reliance upon this authorization.
Neither trcaata acnt; paaymcnt_ cnrcallnaetat or eligibility liar benefits will he conditioned upon
nay providing or refusing to proN isle this authorization.
Information disclosed purstaaaat to this authorization could be re -disclosed by the recipient
and might no longer lac protected I,\ I'cdcraal confidentiality law (I IIPIIA). Ilo v ver, C.:alifiaril a
law prohibits the person receiving my health intbrnaaation From making further disc:losa re of it
unless another authOI-ifaatican fiar such disclosure is obtained from me or unless sa Ch disclosure is
spccificaally rccluired or I-rcral7ittcd by law.
Datccl. August -1. ` 023
(S.SN )
EISENBERG LAW FIRM
P.O. Box 10535
Newport Beach, California 92658
T-%
SANTA ANA CA 9-2,61
16 JAM 20-74 Ptot 4 L,
r
City of Anaheim
Attn: Records Department
200 S. Anaheim Blvd.
Anaheim, CA 92805
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