Patient Confidentiality Contact Form

Patient Confidentiality Contact Form
Patient confidentiality is a top priority at StarBright ABA. Therefore, it is important that you provide us with the following information to ensure there is no violation of your privacy.
In the event that I,   First Name   Last Name, am unable to be reached, StarBright ABA may leave information with the following:

Other adult in household (Name):   First Name   Last Name
On home answering machine(#):   Area Code   Phone Number
On cell phone(#):   Area Code   Phone Number
I may be reached at my work number:   Area Code   Phone Number
May leave a message at my work number:   Yes   No
Other (please describe):

OPT OUT (initials)      in the event that I am unable to be reached, StarBright ABA MAY NOT leave information with anyone but myself. I understand that if the status of any of the above information changes, it will be my responsibility to inform the staff at StarBright ABA.
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