Document ID: acc091f6634bd468d6cb2616d8b2bc74a13f2d09
December 13, 2018
Signed On : https://m14hoops.com

Medical Release Form - Allan Lim


Date: 12/13/2018
Signer Name: Allan Lim
Signer Email: jomart18@comcast.net

Player Name: Josh Lim

Insurance Provider: BCBS
Primary Insurance Holder: Allan Lim
Account Group No: 172177

Emergency Contact: Allan Lim
Phone Number: (630) 965-7564
Relationship: Son

Address:
640 Bennett Dr.

North Aurora, IL 60542
United States

Signed by Allan Lim
Signed on:December 13, 2018

Signature Certificate
Document name: Medical Release Form - Allan Lim
Unique Document ID: acc091f6634bd468d6cb2616d8b2bc74a13f2d09
Allan Lim
Party ID: 4653cddd-88db-4819-aa82-973b129a3b5b
IP Address: 50.207.175.130
Security Level: E-mail
Digital Signature:
Multi-Factor
Digital Fingerprint Checksum
108aa105be5a962d6698ed769f1d3c5a
Timestamp Audit
2018-12-13 16:51:54 CSTMedical Release Form - Allan Lim Uploaded by Matt Miller - medicalform@m14hoops.com IP 71.2.154.132
2018-12-13 16:51:57 CSTDocument viewed by Allan Lim - jomart18@comcast.net IP 50.207.175.130
2018-12-13 16:53:01 CSTDocument signed by Allan Lim - jomart18@comcast.net IP 50.207.175.130
2018-12-13 16:53:01 CSTThe document has been signed by all parties and is now closed.
2018-12-13 23:53:23 CSTDocument viewed by Allan Lim - jomart18@comcast.net IP 54.226.36.60