Get the free New Quitline Fax Referral Form - dhhs ne

NEBRASKA TOBACCO OUTLINE FAX REFERRAL FORM Fax Number: 18004833114 Date Sent: / / Provider Information: CLINIC NAME CLINIC ZIP CODE HEALTH CARE PROVIDER CONTACT NAME FAX NUMBER PHONE NUMBER I AM A

How to fill out new quitline fax referral

How to fill out new quitline fax referral

1. Step 1: Start by downloading the new quitline fax referral form from the official website.
2. Step 2: Fill in the patient's personal information, including their name, date of birth, and contact details.
3. Step 3: Provide the healthcare provider's information, such as their name, clinic name, and contact information.
4. Step 4: Specify the reason for the referral and provide any relevant medical details or notes.
5. Step 5: Make sure to sign and date the referral form.
6. Step 6: Review the completed form for accuracy and completeness.
7. Step 7: Fax the referral form to the designated quitline fax number provided on the form.
8. Step 8: Confirm receipt of the referral by contacting the quitline or checking for a confirmation response.
9. Step 9: Keep a copy of the filled-out referral form for your records.

Who needs new quitline fax referral?

1. Healthcare providers who want to refer their patients to the quitline for smoking cessation support.
2. Patients who are seeking help and support to quit smoking and want their healthcare provider to refer them to the quitline.
3. Individuals who are motivated to quit smoking and are looking for professional guidance and resources.

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What is new quitline fax referral?

New quitline fax referral is a form used to refer individuals to a quitline for help with quitting smoking.

Who is required to file new quitline fax referral?

Healthcare providers and organizations working with individuals who smoke are required to file new quitline fax referral.

How to fill out new quitline fax referral?

To fill out new quitline fax referral, healthcare providers need to provide the patient's contact information, smoking history, and reason for referral.

What is the purpose of new quitline fax referral?

The purpose of new quitline fax referral is to connect individuals who smoke with resources and support to help them quit smoking.

What information must be reported on new quitline fax referral?

The information reported on new quitline fax referral includes patient demographics, smoking history, reason for referral, and healthcare provider information.