• 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,      , am unable to be reached, StarBright ABA may leave information with the following:

    Other adult in household (Name):         
    On home answering machine(#):         
    On cell phone(#):         
    I may be reached at my work number:         
    May leave a message at my work number:         
    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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