Get the free Tobacco-use Program Change Form - oregon

This form is used to change an employee's status in the Tobacco-use Program managed by PEBB, detailing various tobacco-related declarations and initiating necessary payroll deductions.

How to fill out tobacco-use program change form

How to fill out Tobacco-use Program Change Form

1. Obtain the Tobacco-use Program Change Form from the relevant office or website.
2. Fill in your personal information in the designated fields, including your name and contact details.
3. Provide your current tobacco use status, specifying the type and frequency of use.
4. Indicate any changes you wish to make to your tobacco-use program.
5. Review the form for accuracy and ensure all required fields are completed.
6. Sign and date the form to acknowledge the information provided is correct.
7. Submit the completed form to the appropriate department or designated representative.

Who needs Tobacco-use Program Change Form?

1. Individuals enrolled in a tobacco-use program who wish to update their information or change their program status.
2. Healthcare providers managing tobacco-use programs that require adjustments.
3. Administrators or coordinators overseeing tobacco cessation or change initiatives.

People Also Ask about

What is the Medicare policy for 99406?

Medicare Part B covers two levels of tobacco cessation counseling for beneficiaries: intermediate and intensive. Intermediate sessions (code 99406) represent counseling the patient for 3–10 minutes, while intensive sessions (code 99407) describe counseling the patient for greater than 10 minutes.

Do you need modifier 25 with 99406?

Modifier 25 should be used on the claim when billing an E/M service along with the 99406 or 99407. This indicates that you are providing a significant, separately identifiable E/M service on the same day as another procedure or service.

What documentation is required for 99406?

Elements of documentation for CPT codes 99406-99407 may include, but are not limited to: • Type or method of tobacco use (cigarettes, pipe, chewing tobacco, etc.) Impact (personal, family, friends, health, social, financial, etc.)

What are the 5 R's of motivational interviewing?

The clinician can motivate patients to consider a quit attempt with the "5 R's": Relevance, Risks, Rewards, Roadblocks, and Repetition. Relevance - Encourage the patient to indicate why quitting is personally relevant.

What documentation is needed for 99406?

Elements of documentation for CPT codes 99406-99407 may include, but are not limited to: • Type or method of tobacco use (cigarettes, pipe, chewing tobacco, etc.) Impact (personal, family, friends, health, social, financial, etc.)

What are the documentation requirements for smoking cessation counseling?

As such, the following items should be documented in the medical record: The patient/client's willingness to attempt to quit. What was discussed during counseling/treatment planning. Amount of time spent counseling the patient/client. Tobacco use. Advice to quit and impact of smoking provided to patient.

What are the 5 A's of a tobacco cessation program?

Successful intervention begins with identifying users and appropriate interventions based upon the patient's willingness to quit. The five major steps to intervention are the "5 A's": Ask, Advise, Assess, Assist, and Arrange. Ask - Identify and document tobacco use status for every patient at every visit.

For pdfFiller’s FAQs

What is Tobacco-use Program Change Form?

The Tobacco-use Program Change Form is a document used to notify and officially record changes to the tobacco-use cessation program within an organization or health initiative.

Who is required to file Tobacco-use Program Change Form?

Individuals or organizations that implement or manage tobacco-use cessation programs are required to file the Tobacco-use Program Change Form whenever there are significant changes to the program.

How to fill out Tobacco-use Program Change Form?

To fill out the Tobacco-use Program Change Form, provide required information such as organization details, description of the changes, reasons for changes, and any relevant dates or timelines associated with the program.

What is the purpose of Tobacco-use Program Change Form?

The purpose of the Tobacco-use Program Change Form is to ensure proper documentation of any modifications in tobacco cessation programs, helping to maintain compliance and provide transparency.

What information must be reported on Tobacco-use Program Change Form?

The information that must be reported includes the name of the organization, contact information, a detailed description of the changes being made, the rationale for those changes, and effective dates of the changes.