North Star Information Request for Professionals
 

Please do not use this form, or electronic mail, to discuss your medical condition, medical history, or private health information. It is not encrypted, and we cannot guarantee your privacy if you include sensitive information about yourself.

 

I would like to find out more about North Star Behavioral Health programs and services as described below. Please contact me with more information.

   
Your Name: __________________________
Title: __________________________
Organization: __________________________
Address: __________________________
City: __________________________
State: __________________________
Zip: __________________________
Telephone (office/cell if preferred): __________________________
Fax: __________________________
E-mail: __________________________
Best time time of day to reach me: __________________________a.m./p.m.
Best method to reach me: __________________________
I would like more information about:
Hospital treatment Child Teen Family Program
Residential treatment Wilderness-based residential treatment
Other (please describe) __________________________
Additional Information:

__________________________
__________________________
__________________________
__________________________

   
Please print and fax completed form to (907)279-1438. A North Star staff member will contact you. Thank you for your interest.
 
(907) 258-7575
(800) 478-7575 (in Alaska)
northstarinfo@uhsinc.com