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

Request Alternate Means and/or Location for Communication

of Healthcare Information

This form is to request that and alternate means and/or location be used for communication of all healthcare and/or personal information concerning patient:

_________________________________________________________________________________

ALTERNATE MEANS OF COMMUNICATIONS:

Until this date _______________________________ or until further written instructions are given:

[] Please FAX all communications to me at this telephone number ___________________________

[] Please email all communications to me at this email address

_________________________________________________________________________________________

It has been explained to me and I understand and accept that email is not a secure transmission medium so the security of any information sent via email cannot be guaranteed. Use it anyway.

[] Please use this medium for all communications to me ______________________________________________________________

___________________________________________________________________________________________________________

ALTERNATE LOCATION FOR COMMUNICATIONS:

Until this date ________________________________ or until further written instructions are given,

please send all communications to me at the following location:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

HANDLING OF PAYMENTS:

Unless the doctor and I have made specific written and mutually acceptable arrangements (not shown on this form) payments will be sent to you via the U.S. Mail and I will remain responsible for seeing that payments are made in a timely manner.

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