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

Request For Patient Healthcare Information

This form is to request protected healthcare information which you maintain on patient

_____________________________________________________________________. Please provide this information in the form of

[] photocopies

[] other media, ____________________________________________________________________

^{specify media requested}

[] Please mail the resulting information to me at this address:

___________________________________________________________________________

___________________________________________________________________________

______________________________________State ________________ ZIP ____________

[] Please, contact me when the information is ready and I will arrange to pick it up at your office myself.

[] Please, contact me when the information is ready. I hereby authorize you to give it to

[]Mr. []Ms. _______________________________________________________________________

or

[]Mr. []Ms. _______________________________________________________________________

I understand that you cannot give this information to anyone other than me or the person(s) I have herein authorized to receive it.

I have read your Notice of Privacy Policies and I understand that I may be charged on a reasonable cost-based basis for all expenses incurred in honoring this request for information, including, but not limited to, a per-page copying cost, an hourly cost for staff time required to locate and copy the information, and mailing costs if I request that the information be mailed to me.

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