Request Added Restrictions on Healthcare Information



	Dr. David R. Winchester, D.M.D., P.C. Request Additional Restrictions on Healthcare Information This form is to request that additional restrictions be placed on the use and/or disclosure of protected healthcare information for patient: _________________________________________________________________________________ The requested additional restrictions and the reasons for them are as follows: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ If more space is needed, please, attach pages as needed. I have read your Notice of Privacy Policies and I understand that you are not required to add these restrictions. I further understand that if you agree to add the requested restrictions, you will adhere to them and that I can cancel these added restrictions at any time I choose, but only by giving you written instructions advising you 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