Get the free QuitlineFaxReferralFormSample.doc - michigancancer

Michigan Tobacco Quit line FAX Referral Form Fax Number: 18004833114 Fax Sent Date: 02 / 10 / 2011 Provider Information: Clinic Name: District Health Department #1 Health Care Provider: WISEMAN Fax

How to fill out quitlinefaxreferralformsampledoc - michigancancer

How to Fill Out quitlinefaxreferralformsampledoc - michigancancer:

1. Start by downloading the quitlinefaxreferralformsampledoc - michigancancer from the Michigan Cancer Consortium website.
2. Open the form using a PDF reader or editor.
3. Begin by filling out your personal information, such as your name, address, phone number, and email address.
4. Provide information about the referring healthcare provider, including their name, clinic or hospital name, address, phone number, and email.
5. Fill in the patient information section, which includes the patient's name, date of birth, sex, race, ethnicity, and smoking status.
6. Specify the reason for the referral, such as the patient's desire to quit smoking, recent diagnosis of a smoking-related illness, or recommendation from their healthcare provider.
7. Indicate whether the patient is ready to quit smoking or if they need assistance or more information before making a decision.
8. Include any additional notes or relevant information in the designated space provided.
9. Once you have completed filling out the form, save it or print it as necessary.
10. Submit the quitlinefaxreferralformsampledoc - michigancancer to the appropriate healthcare provider or organization as instructed.

Who Needs quitlinefaxreferralformsampledoc - michigancancer:

1. Healthcare professionals who are referring patients to smoking cessation services or resources.
2. Patients who are seeking assistance or support to quit smoking and have been referred by their healthcare providers.
3. Organizations or programs that provide smoking cessation services or resources and require a referral form for documentation purposes.

Overall, the quitlinefaxreferralformsampledoc - michigancancer is a useful tool for facilitating communication and referral between healthcare professionals, patients, and smoking cessation programs in Michigan.

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What is quitlinefaxreferralformsampledoc - michigancancer?

It is a sample document used to refer individuals to the Michigan Cancer Quitline.

Who is required to file quitlinefaxreferralformsampledoc - michigancancer?

Healthcare providers and organizations who want to refer patients to the Michigan Cancer Quitline.

How to fill out quitlinefaxreferralformsampledoc - michigancancer?

The form should be filled out with the patient's information and reason for referral, then sent to the Michigan Cancer Quitline.

What is the purpose of quitlinefaxreferralformsampledoc - michigancancer?

The purpose is to facilitate referrals of individuals who want to quit smoking to the Michigan Cancer Quitline for support and resources.

What information must be reported on quitlinefaxreferralformsampledoc - michigancancer?

Patient's name, contact information, smoking history, and reason for referral must be reported.