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April 2016 Tobacco Cessation Physician Affidavit Form. The Texas A&M University System employees and their spouses who are covered under the A&M System.
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How to fill out tobacco cessation physician affidavit
To fill out the tobacco cessation physician affidavit, follow these steps:
01
Download the tobacco cessation physician affidavit form from the relevant authority's website or obtain a physical copy from a healthcare provider.
02
Fill in your personal information, such as your full name, contact details, and professional credentials, in the designated fields.
03
Provide the date on which the affidavit is being filled out.
04
Indicate the patient's information accurately, including their name, date of birth, and any relevant medical history or conditions related to their tobacco use.
05
Describe the tobacco cessation treatment plan that you have recommended for the patient. Include details such as the date of initiation, the type of intervention (e.g., counseling, medication, or a combination), and the estimated duration of the treatment.
06
If applicable, mention any support services or resources that you have suggested to the patient to aid in their tobacco cessation journey.
07
Sign and date the affidavit to certify that the information provided is accurate and based on your professional knowledge and expertise.
Who needs tobacco cessation physician affidavit?
A tobacco cessation physician affidavit is often required for individuals who are participating in certain programs or seeking benefits related to tobacco cessation. These may include:
01
Employees who are enrolled in workplace wellness programs that offer incentives or rewards for quitting tobacco use.
02
Individuals applying for health insurance policies or coverage that offer reduced rates or additional benefits to non-smokers.
03
Patients seeking reimbursement for tobacco cessation medications or counseling services from their health insurance provider.
04
Participants in research studies or clinical trials focused on tobacco cessation.
It is advisable to consult the specific guidelines or requirements of the program or institution to determine if a tobacco cessation physician affidavit is necessary.
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What is tobacco cessation physician affidavit?
Tobacco cessation physician affidavit is a document signed by a physician confirming the patient's efforts to quit using tobacco products.
Who is required to file tobacco cessation physician affidavit?
Patients who are participating in tobacco cessation programs are required to file the tobacco cessation physician affidavit.
How to fill out tobacco cessation physician affidavit?
Patients need to visit their physician, who will assess their progress in quitting tobacco and, if successful, sign the affidavit.
What is the purpose of tobacco cessation physician affidavit?
The purpose of the tobacco cessation physician affidavit is to document the patient's participation in and progress with tobacco cessation programs.
What information must be reported on tobacco cessation physician affidavit?
The tobacco cessation physician affidavit must include the patient's name, the physician's signature, and the dates of participation in tobacco cessation programs.
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