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 CDTMedical release Uploaded by Amy Hitchinson - ahitchinson@theivyacademy.org IP 77.99.32.61
February 20, 2018 11:01 am CDTDil 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 CDTAmy 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 CDTLorena 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 CDTDil 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 CDTAmy 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 CDTLorena 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 CDTDil 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 CDTAmy 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 CDTLorena 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 CDTJeanette 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 CDTDil 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 CDTAmy 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 CDTLorena 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 CDTJeanette 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 CDTDil 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 CDTAmy 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 CDTLorena 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 CDTJeanette 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 CDTAmy 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 CDTDil 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 CDTAmy 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 CDTLorena 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 CDTJeanette 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 CDTDil 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 CDTAmy 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 CDTLorena 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 CDTJeanette 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 CDTReception 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 CDTDil 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 CDTAmy 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 CDTLorena 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 CDTReception 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 CDTLorena 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 CDTReception 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 CDTAmy 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 CDTDil 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 CDTLorena 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 CDTReception 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 CDTDil 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 CDTLorena 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 CDTReception 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 CDTDil 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 CDTLorena 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 CDTReception 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 CDTDil 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 CDTLorena 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 CDTAmy 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 CDTDil 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 CDTLorena 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 CDTAmy 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 CDTDil 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 CDTDanielle 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 CDTLorena 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 CDTAmy 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 CDTDil 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 CDTDanielle 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 CDTLorena 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 CDTAmy 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 CDTDil 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 CDTDanielle 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 CDTLorena 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 CDTAmy 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 CDTDil 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 CDTJessica 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 CDTLorena 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 CDTAmy 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 CDTDil 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 CDTJessica 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 CDTKarina 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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