Document ID: 923eb02eac26d7e7cfecdaaa590a0e051c604227
January 11, 2019
Signed On : https://m14hoops.com

Medical Release Form - Jennie Burton


Date: 01/11/2019
Signer Name: Jennie Burton
Signer Email: jburton@ameripath.com

Player Name: Mason Gomez

Insurance Provider: Aetna
Primary Insurance Holder: Jennifer Burton
Account Group No: 81892502100002

Emergency Contact: Jennie Burton
Phone Number: (317) 746-4259
Relationship: Mother

Address:
5931 Laketon Drive

Indianapolis, IN 46220
United States

Signed by Jennie Burton
Signed on:January 11, 2019

Signature Certificate
Document name: Medical Release Form - Jennie Burton
Unique Document ID: 923eb02eac26d7e7cfecdaaa590a0e051c604227
Jennie Burton
Party ID: 448d2644-ea5a-4255-a066-5badc3b03b4b
IP Address: 172.58.141.133
Security Level: E-mail
Digital Signature:
Multi-Factor
Digital Fingerprint Checksum
c0c1489cc9a898c386220daac879e4a2
Timestamp Audit
2019-01-11 14:26:14 CDTMedical Release Form - Jennie Burton Uploaded by Matt Miller - medicalform@m14hoops.com IP 71.2.154.132
2019-01-11 14:26:17 CDTDocument viewed by Jennie Burton - jburton@ameripath.com IP 172.58.141.133
2019-01-11 14:26:30 CDTDocument signed by Jennie Burton - jburton@ameripath.com IP 172.58.141.133
2019-01-11 14:26:31 CDTThe document has been signed by all parties and is now closed.
2019-01-11 16:54:11 CDTDocument viewed by Jennie Burton - jburton@ameripath.com IP 172.58.141.133
2019-01-12 05:33:55 CDTDocument viewed by Jennie Burton - jburton@ameripath.com IP 107.23.176.162
2019-01-21 22:44:13 CDTDocument viewed by Jennie Burton - jburton@ameripath.com IP 3.80.55.37
2019-03-20 23:26:45 CDTDocument viewed by Jennie Burton - jburton@ameripath.com IP 34.228.55.57