Get the free QuitlineNC FAX REFERRAL FORM

This form is used for referring individuals to QuitlineNC for smoking cessation assistance. It captures the essential details of the referring party and the person being referred, including contact

How to fill out quitlinenc fax referral form

How to fill out QuitlineNC FAX REFERRAL FORM

1. Obtain the QuitlineNC FAX REFERRAL FORM from the official website or your healthcare provider.
2. Fill in the patient's information, including name, date of birth, and contact details.
3. Indicate the reason for the referral and any relevant medical history related to smoking or tobacco use.
4. Provide the referring person's information, including name, phone number, and relationship to the patient.
5. Sign and date the form to confirm the referral.
6. Fax the completed form to QuitlineNC's designated fax number.

Who needs QuitlineNC FAX REFERRAL FORM?

1. Healthcare providers who want to refer patients for tobacco cessation support.
2. Individuals who are seeking assistance in quitting smoking or using tobacco.
3. Organizations or community programs that support smoking cessation initiatives.

For pdfFiller’s FAQs

What is QuitlineNC FAX REFERRAL FORM?

The QuitlineNC FAX REFERRAL FORM is a document used by healthcare providers to refer patients to Quitline North Carolina, a statewide program that offers support and resources to individuals who want to quit smoking or using tobacco.

Who is required to file QuitlineNC FAX REFERRAL FORM?

Healthcare providers, including doctors, nurses, and other medical professionals who are involved in the care of patients who use tobacco, are required to fill out the QuitlineNC FAX REFERRAL FORM when they wish to refer patients to the quitline for assistance.

How to fill out QuitlineNC FAX REFERRAL FORM?

To fill out the QuitlineNC FAX REFERRAL FORM, healthcare providers need to provide patient information such as name, contact details, tobacco use history, and the provider's information. After completing the form, it should be faxed to the Quitline.

What is the purpose of QuitlineNC FAX REFERRAL FORM?

The purpose of the QuitlineNC FAX REFERRAL FORM is to facilitate the referral process for patients to receive dedicated support and counseling from Quitline North Carolina, helping them to successfully quit using tobacco.

What information must be reported on QuitlineNC FAX REFERRAL FORM?

The information that must be reported on the QuitlineNC FAX REFERRAL FORM includes the patient's name, phone number, date of birth, tobacco use status, healthcare provider's name and contact information, and any specific notes relevant to the referral.