LHL- Consent to Release Information Form

Page 1

LH Langley, PLLC
910-679-4424 (Phone)
910-679-4478 (Fax)

www.laurenlangleydnp.com (Website)
llangleyoffice@gmail.com (Email)

1017 Ashes Drive, STE 104,
Wilmington, NC 28405

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

Patient name:

Date of birth:

This authorization allows Lauren Langley, DNP/LH Langley, PLLC to

Disclose information to

Request information from

Name (or title) and organization:

Address:

City:

State:

Zip:

Phone:

Fax:

I. Purpose of Disclosure

This form, when completed and signed by you, authorizes the mutual exchange of protected health information from your clinical record to the person you designate. I authorize Lauren Langley, DNP, and/or her administrative staff to disclose the following health care information (check all that apply):

All of my health information for the date(s)

through

My health information relating to the following treatment or conditions:

Psychological reports

Medications

Lab Reports

Previous Notes/ Medical Record

Other

I authorize this exchange for the following reasons (check all that apply):

Individual request

Continuity/Coordination of care

Treatment planning

Evaluation

Other

II. My Rights

I understand this information will not be further released without my consent.
This authorization will expire on the date that is 10(10) years from the date of my signature below. I understand that I may revoke this Authorization in writing at any time except to the extent that information or action has already been taken by Dr. Langley prior to this revocation.

Patient or legally authorized individual signature

Date

Printed Name if signed on behalf of patient