Get the free Mississippi Tobacco Quitline Fax Referral/Consent Form

This form is used for healthcare providers to refer patients to the Mississippi Tobacco Quitline for tobacco cessation support. It includes patient and provider information, consent for treatment,

How to fill out mississippi tobacco quitline fax

How to fill out Mississippi Tobacco Quitline Fax Referral/Consent Form

1. Obtain the Mississippi Tobacco Quitline Fax Referral/Consent Form from the official website or your health provider.
2. Fill out the patient's name, address, phone number, and date of birth in the designated fields.
3. Indicate the preferred contact method for the patient (e.g., phone, text).
4. Provide the name and contact information of the referring individual (e.g., healthcare provider).
5. Check the boxes to indicate consent for the Quitline to contact the patient.
6. Complete any additional required information regarding the patient's tobacco use history.
7. Sign and date the form at the bottom to affirm that the information is correct and consent is granted.
8. Fax the completed form to the Mississippi Tobacco Quitline at the number provided on the form.

Who needs Mississippi Tobacco Quitline Fax Referral/Consent Form?

1. Individuals who are trying to quit using tobacco products.
2. Healthcare providers referring patients to cessation support services.
3. Community organizations assisting individuals with tobacco cessation.

For pdfFiller’s FAQs

What is Mississippi Tobacco Quitline Fax Referral/Consent Form?

The Mississippi Tobacco Quitline Fax Referral/Consent Form is a document used to refer individuals seeking help to quit tobacco use to the Mississippi Tobacco Quitline, allowing the Quitline to provide necessary support and resources.

Who is required to file Mississippi Tobacco Quitline Fax Referral/Consent Form?

Healthcare providers, counselors, or any authorized individuals assisting someone who wants to quit tobacco are required to file the Mississippi Tobacco Quitline Fax Referral/Consent Form.

How to fill out Mississippi Tobacco Quitline Fax Referral/Consent Form?

To fill out the form, provide the individual's personal information, including name and contact details, as well as the referring provider's information and sign the consent section to allow communication with the Quitline.

What is the purpose of Mississippi Tobacco Quitline Fax Referral/Consent Form?

The purpose of the form is to facilitate the referral process to the Quitline and ensure that the individual receives timely support to quit tobacco while also obtaining consent for sharing information.

What information must be reported on Mississippi Tobacco Quitline Fax Referral/Consent Form?

The form must report the individual's name, phone number, date of birth, referring provider's details, and the signature of the individual giving consent for communication and services provided by the Quitline.