PRIVACY STATEMENTS
DESIGNATION OF DISCLOSURE
Acknowledgement of Privacy Notice
Our Notice of Privacy Practice provides information about how we may use
and disclose protected health information (PHI) about you. You have the right to review
our NOTICE and ask questions about our privacy practices. As provided in our
NOTICE, the terms of our NOTICE may change. If we change our NOTICE, you may
request a revised copy by calling the office.
You have the right to request that we restrict how PHI about you is used or
disclosed for treatment, payment or health care operations.
By signing this form you acknowledge that you have reviewed our PRIVACY
PRACTICES.
PATIENT'S NAME, DOB, SIGNATURE OF PATIENT ________________________
TODAY'S DATE _____________________________
DESIGNATION OF CERTAIN RELATIVES, CLOSE FRIENDS & OTHER
CAREGIVERS. __________________________________________________
I agree that Dr. Cunningham may disclose certain information about my health
to a family member, close personal friend, or other care givers. In that case Dr.
Cunningham's office will disclose only that information relevant to that individual's
involvement in my care.
I designate the following persons listed below as persons involved with my
health care for the purpose of Dr. Cunningham making the limited disclosures described
above.
I understand that I am not required to list anyone. I also understand that I may
change this list at any time in writing.
PRINT NAME _____________________________________________
RELATIONSHIP ____________________________________________
PRINT NAME ______________________________________________
RELATIONSHIP _____________________________________________
CONTACT INFO
Please Designate How You Would Like To Be Contacted By Our Office.
1. Home phone ___________________________
It is ok to leave a detailed message at this number.
Yes _____ No ______
Cell phone ______________________________
It is ok to leave a detailed message or text message at this number.
We do not sell your information for any marketing/promotional purposes
Yes _____ No ______
3. Mailing address _________________________
It is ok to send me detailed information by mail.
Yes ______ No ______
4. E-Mail ________________________________
It is ok to send me detailed information about appointment or office
information by e-mail.
Yes ____ No ______ Last updated 5/5/2025
DESIGNATION OF DISCLOSURE
Acknowledgement of Privacy Notice
Our Notice of Privacy Practice provides information about how we may use
and disclose protected health information (PHI) about you. You have the right to review
our NOTICE and ask questions about our privacy practices. As provided in our
NOTICE, the terms of our NOTICE may change. If we change our NOTICE, you may
request a revised copy by calling the office.
You have the right to request that we restrict how PHI about you is used or
disclosed for treatment, payment or health care operations.
By signing this form you acknowledge that you have reviewed our PRIVACY
PRACTICES.
PATIENT'S NAME, DOB, SIGNATURE OF PATIENT ________________________
TODAY'S DATE _____________________________
DESIGNATION OF CERTAIN RELATIVES, CLOSE FRIENDS & OTHER
CAREGIVERS. __________________________________________________
I agree that Dr. Cunningham may disclose certain information about my health
to a family member, close personal friend, or other care givers. In that case Dr.
Cunningham's office will disclose only that information relevant to that individual's
involvement in my care.
I designate the following persons listed below as persons involved with my
health care for the purpose of Dr. Cunningham making the limited disclosures described
above.
I understand that I am not required to list anyone. I also understand that I may
change this list at any time in writing.
PRINT NAME _____________________________________________
RELATIONSHIP ____________________________________________
PRINT NAME ______________________________________________
RELATIONSHIP _____________________________________________
CONTACT INFO
Please Designate How You Would Like To Be Contacted By Our Office.
1. Home phone ___________________________
It is ok to leave a detailed message at this number.
Yes _____ No ______
Cell phone ______________________________
It is ok to leave a detailed message or text message at this number.
We do not sell your information for any marketing/promotional purposes
Yes _____ No ______
3. Mailing address _________________________
It is ok to send me detailed information by mail.
Yes ______ No ______
4. E-Mail ________________________________
It is ok to send me detailed information about appointment or office
information by e-mail.
Yes ____ No ______ Last updated 5/5/2025