Dr. David R. Winchester, D.M.D., P.C.

Appointment of Personal Representative for Disclosure

of Healthcare Information

This form is to appoint a personal representative to whom you are instructed to disclose all of my healthcare and/or personal information that you maintain.

___________________________________________________________________________________________________________

is hereby appointed as said personal representative. Until you receive a written cancellation of this appointment, you are instructed to make available to this personal representative all of the healthcare and/or personal information you maintain about patient:

_________________________________________________________________________________

Note that this appointment does not give the appointed personal representative control over the patient's healthcare, nor does it grant this person any rights whatsoever to handle financial, medical, dental, or other decisions for the named patient. This appointment only grants to the appointed personal representative the right to disclosure of the healthcare and/or personal information you maintain concerning the patient named above.

I have read your Notice of Privacy Policies and I understand that I may cancel this person's status as a personal representative at any time, but only by giving you written notice to do so.

Signature _________________________________________________________________ Date _____________________________

If this form is signed by a personal representative of the patient, please, complete the following:

Personal Representative's Name ________________________________________________________________________________

Relationship to Patient ________________________________________________________________________________________

Mail or deliver the completed form to:

Dr. David R. Winchester

Suite 100

2500 Center Point Parkway

Center Point, AL 35215