Get the free Quitline Fax Referral Form - NC BCCCP Home

QuitlineNC FAX REFERRAL FORM Fax completed form to: 1-800-483-3114 Referring Organization Information: Please circle either one or both programs: Organization Name: Date Fax Sent: / / CCCP / NC WISEMAN

How to fill out quitline fax referral form

To fill out the quitline fax referral form, follow these steps:

1. Go to the official website of the quitline program or call their helpline to obtain the referral form.
2. Begin by providing your personal information such as your name, contact number, and address. Some forms may also require your date of birth or other relevant details.
3. Indicate the name and contact information of the healthcare provider who is referring you to the quitline program. This may include their name, clinic name, address, phone number, and fax number.
4. Provide any additional information that may be required, such as your healthcare provider's license number or National Provider Identifier (NPI). This information helps in ensuring the validity of the referral.
5. Review the completed form for any errors or missing information. Make sure all the details are accurate and legible.
6. Once you are satisfied that the form is complete, fax it to the designated fax number provided by the quitline program. Double-check the fax number to ensure it is correct.
7. Keep a copy of the fax referral form for your records.

Who needs the quitline fax referral form?

Individuals who want to access the services offered by the quitline program and are being referred by a healthcare provider need to fill out the quitline fax referral form. This form acts as a formal referral and helps the quitline program to provide appropriate support to the individual in their journey to quit smoking or tobacco use. The form allows the healthcare provider to communicate important information about the patient, ensuring a more personalized approach to quitting tobacco.

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What is quitline fax referral form?

The quitline fax referral form is a document used to refer individuals to a quitline program via fax.

Who is required to file quitline fax referral form?

Healthcare providers and organizations that are participating in a quitline program are required to file the quitline fax referral form.

How to fill out quitline fax referral form?

To fill out the quitline fax referral form, you need to provide the required information about the individual being referred, including their name, contact information, and relevant health details.

What is the purpose of quitline fax referral form?

The purpose of the quitline fax referral form is to facilitate the referral of individuals to quitline programs, which provide support and resources for smoking cessation.

What information must be reported on quitline fax referral form?

The quitline fax referral form typically requires reporting of the individual's name, contact information, smoking history, and any relevant health information.