Get the free FAX-TO-QUIT Referral Form

This form is used to refer individuals to the West Virginia Tobacco Quitline for assistance with quitting tobacco. It collects essential patient information and consent for services.

How to fill out fax-to-quit referral form

How to fill out FAX-TO-QUIT Referral Form

1. Obtain the FAX-TO-QUIT Referral Form from a reputable health organization or website.
2. Fill in the patient's personal details including name, contact information, and date of birth.
3. Provide the healthcare provider's details such as name, address, and phone number.
4. Indicate the reason for the referral and any relevant medical history regarding tobacco use.
5. Check for eligibility criteria and ensure all sections are completed accurately.
6. Sign and date the form, ensuring that the patient's consent is noted if required.
7. Fax the completed form to the designated number provided on the form.

Who needs FAX-TO-QUIT Referral Form?

1. Individuals who are seeking help to quit smoking or using tobacco products.
2. Healthcare providers who are referring patients to smoking cessation programs.
3. Community organizations that assist with smoking cessation efforts.

For pdfFiller’s FAQs

What is FAX-TO-QUIT Referral Form?

The FAX-TO-QUIT Referral Form is a document used to refer individuals to smoking cessation programs, providing them with resources and support to quit smoking.

Who is required to file FAX-TO-QUIT Referral Form?

Healthcare providers, including doctors, nurses, and counselors, are required to file the FAX-TO-QUIT Referral Form for patients who are seeking assistance with quitting smoking.

How to fill out FAX-TO-QUIT Referral Form?

To fill out the FAX-TO-QUIT Referral Form, you need to provide patient information, including their name, contact details, and smoking history, as well as the referrer’s information and any relevant notes or recommendations.

What is the purpose of FAX-TO-QUIT Referral Form?

The purpose of the FAX-TO-QUIT Referral Form is to facilitate the referral process for individuals who want to quit smoking, ensuring they receive the necessary support and resources promptly.

What information must be reported on FAX-TO-QUIT Referral Form?

The information that must be reported on the FAX-TO-QUIT Referral Form includes the patient's name, contact information, date of birth, smoking status, the referrer’s name and contact information, and any specific requests or notes regarding the patient's cessation needs.