Get the free Quitline FAX Referral Form - CT.gov - www2 massgeneral

CONNECTICUT OUTLINE FAX REFERRAL FORM Fax Number: 1-800-483-3114 FAX SENT DATE: / / Provider Information: CLINIC NAME CLINIC ZIP CODE HEALTH CARE PROVIDER CONTACT NAME FAX NUMBER PHONE NUMBER I AM

How to fill out quitline fax referral form

How to fill out quitline fax referral form:

1. Obtain the quitline fax referral form from the appropriate organization or agency. This form is typically available online or through a designated helpline.
2. Read the instructions carefully to understand the purpose of the form and the information required.
3. Fill in your personal details accurately, such as your name, contact information, and any relevant identification numbers or codes.
4. Provide information about your tobacco usage, including the type of tobacco products used and the frequency of use.
5. Indicate the reason for seeking assistance or referral through the quitline. This could include a desire to quit smoking, seeking resources or support, or a recommendation from a healthcare professional. Be as specific as possible.
6. If applicable, provide information about any previous quit attempts, cessation methods used, or current medication or treatment for tobacco addiction.
7. Review the form for any errors or missing information. Make sure all sections are completed before submitting.
8. Sign and date the form, indicating your consent for the information provided to be shared with relevant parties for assistance or follow-up.
9. Submit the completed form via fax to the designated quitline or organization as instructed. Keep a copy of the form for your records.

Who needs quitline fax referral form?

1. Individuals who want to quit smoking or using tobacco products and are seeking assistance or support.
2. Healthcare professionals who want to refer their patients to a quitline for help with tobacco cessation.
3. Organizations or agencies involved in providing tobacco cessation services or resources to the community.

For pdfFiller’s FAQs

How can I modify quitline fax referral form without leaving Google Drive?

People who need to keep track of documents and fill out forms quickly can connect PDF Filler to their Google Docs account. This means that they can make, edit, and sign documents right from their Google Drive. Make your quitline fax referral form into a fillable form that you can manage and sign from any internet-connected device with this add-on.

How do I execute quitline fax referral form online?

With pdfFiller, you may easily complete and sign quitline fax referral form online. It lets you modify original PDF material, highlight, blackout, erase, and write text anywhere on a page, legally eSign your document, and do a lot more. Create a free account to handle professional papers online.

How do I complete quitline fax referral form on an iOS device?

Install the pdfFiller app on your iOS device to fill out papers. Create an account or log in if you already have one. After registering, upload your quitline fax referral form. You may now use pdfFiller's advanced features like adding fillable fields and eSigning documents from any device, anywhere.

What is quitline fax referral form?

The Quitline Fax Referral form is a document used to refer individuals to a quitline service for help with quitting smoking or tobacco use.

Who is required to file quitline fax referral form?

Healthcare providers and organizations that offer tobacco cessation services 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 will need to provide the individual's contact information, demographics, tobacco use history, and reason for referral. You will also need to include your own contact information and any additional notes or comments.

What is the purpose of quitline fax referral form?

The purpose of the Quitline Fax Referral form is to facilitate the referral process for individuals seeking help with quitting smoking or tobacco use. It allows healthcare providers and organizations to easily connect individuals with the appropriate quitline services.

What information must be reported on quitline fax referral form?

The Quitline Fax Referral form requires reporting of the individual's contact information, demographics, tobacco use history, reason for referral, and any additional notes or comments. Healthcare providers or organizations may also need to provide their own contact information and relevant details.