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

Cancel Appointment of Personal Representative for Disclosure

of Healthcare Information

This form is to cancel the appointment of a personal representative to whom you were previously instructed to disclose all of my healthcare and/or personal information that you maintain. Appointment of

___________________________________________________________________________________________________________

as a personal representative is hereby revoked and all rights and privileges granted under the appointment as personal representative of patient

_________________________________________________________________________________

are hereby cancelled immediately.

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