Request Amendment of Healthcare Information



	Dr. David R. Winchester, D.M.D., P.C. Request Amendment of Healthcare Information This form is to request that an amendment be made to the protected healthcare information you maintain for patient: _________________________________________________________________________________ The requested amendment(s) 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 honor this request. 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