The Ivy Academy of Early Learning

Medical release


Authorization to use and disclosure individually identifiable health information

Patient's Name:  
Patient's DOB:  
Patient's SSN/ITIN:   

Parent/Guardian name:   
Relationship to patient:   
SSN/ITIN:   
Telephone number:  /  


I hereby authorize the use and disclosure by The Ivy Academy of Early Learning, Inc of the individually identifiable health information about me that is described below for the specific purpose listed below. I understand that such uses and disclosures may only be made by, and only to the persons or organization identified below.

 

Specific description of health information to be used or disclosed:
Immunization Record, TB Testing, Lead Testing

 

Purpose of the use or disclosure:
Update of Health Record

 


Person or organization using or disclosing the information:

 

 

 

Person or organization receiving the information:

 

 

 

 

I understand that my decision to sign this form and authorize this use and disclosure of health information about me, as described above is voluntary and that I may refuse to sign this form.

 

Leave this empty:

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Signature Certificate
Document name: Medical release
lock iconUnique Document ID: 9bfb513593e3332d5f32822f8eac79224ddc8cad
Timestamp Audit
October 6, 2017 5:48 am CSTMedical release Uploaded by Amy Hitchinson - ahitchinson@theivyacademy.org IP 77.99.32.61
February 20, 2018 11:01 am CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 165.225.80.244
February 20, 2018 11:01 am CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 165.225.80.244
February 20, 2018 11:01 am CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 165.225.80.244
August 29, 2018 2:45 pm CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.231.184
August 29, 2018 2:45 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.231.184
August 29, 2018 2:45 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.231.184
December 13, 2019 5:44 pm CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 13, 2019 5:44 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 13, 2019 5:44 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 13, 2019 5:44 pm CSTJeanette Mihalec - jmihalec@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 16, 2019 8:21 pm CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 16, 2019 8:21 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 16, 2019 8:21 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 16, 2019 8:21 pm CSTJeanette Mihalec - jmihalec@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 17, 2019 8:14 am CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 17, 2019 8:14 am CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 17, 2019 8:14 am CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 17, 2019 8:14 am CSTJeanette Mihalec - jmihalec@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 17, 2019 8:14 am CSTAmy Hitchinson - ahitchinson@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
December 17, 2019 5:15 pm CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 213.205.194.140
December 17, 2019 5:15 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 213.205.194.140
December 17, 2019 5:15 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 213.205.194.140
December 17, 2019 5:15 pm CSTJeanette Mihalec - jmihalec@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 213.205.194.140
April 30, 2020 7:43 pm CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
April 30, 2020 7:43 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
April 30, 2020 7:43 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
April 30, 2020 7:43 pm CSTJeanette Mihalec - jmihalec@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
April 30, 2020 7:43 pm CSTReception Team - reception@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 86.21.181.23
February 14, 2021 4:34 pm CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 14, 2021 4:34 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 14, 2021 4:35 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 14, 2021 4:35 pm CSTReception Team - reception@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 18, 2021 9:07 am CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 18, 2021 9:07 am CSTReception Team - reception@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 18, 2021 9:07 am CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 18, 2021 9:08 am CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 27, 2021 9:37 am CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 27, 2021 9:37 am CSTReception Team - reception@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 27, 2021 9:37 am CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 27, 2021 12:35 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 27, 2021 12:35 pm CSTReception Team - reception@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
February 27, 2021 12:35 pm CSTDil Ahdan - ivyenrollment@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
May 18, 2021 5:52 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
May 18, 2021 5:52 pm CSTReception Team - reception@theivyacademy.org added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
May 18, 2021 5:52 pm CSTDil Ahdan - ivyenrollment@1da.co added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
May 27, 2021 5:20 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
May 27, 2021 5:20 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
May 27, 2021 5:20 pm CSTDil Ahdan - ivyenrollment@1da.co added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
August 25, 2021 5:23 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
August 25, 2021 5:23 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
August 25, 2021 5:23 pm CSTDil Ahdan - ivyenrollment@1da.co added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
August 25, 2021 5:23 pm CSTDanielle Galvan - dgalvan@theivyacademy.org added by Amy Hitchinson - theivyacademy@ymail.com as a CC'd Recipient Ip: 77.99.32.61
September 20, 2022 5:34 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 18.217.59.22
September 20, 2022 5:34 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 18.217.59.22
September 20, 2022 5:34 pm CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 18.217.59.22
September 20, 2022 5:34 pm CSTDanielle Galvan - dgalvan@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 18.217.59.22
September 20, 2022 5:35 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 18.217.59.22
September 20, 2022 5:35 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 18.217.59.22
September 20, 2022 5:35 pm CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 18.217.59.22
September 20, 2022 5:35 pm CSTDanielle Galvan - dgalvan@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 18.217.59.22
September 1, 2023 11:10 am CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
September 1, 2023 11:10 am CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
September 1, 2023 11:10 am CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
September 1, 2023 11:10 am CSTJessica Rogers - jemerson@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
September 10, 2023 5:40 pm CSTLorena Delgado - ldelgado@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
September 10, 2023 5:40 pm CSTAmy Hitchinson - theivyacademy@ymail.com added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
September 10, 2023 5:40 pm CSTDil Ahdan - dil@1da.co added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
September 10, 2023 5:40 pm CSTJessica Rogers - jemerson@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
September 10, 2023 5:40 pm CSTKarina Cortez - kcortez@theivyacademy.org added by Amy Hitchinson - ahitchinson@theivyacademy.org as a CC'd Recipient Ip: 77.99.32.61
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