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ODB-801 Rev. 9/08 Tobacco Use Declaration A Member Information (must complete) Member name SSN Address City State Birth date (mm/dd/by) Phone (Zip) Tobacco Free Declaration I declare that I have not

How to fill out tobacco use declaration

How to fill out tobacco use declaration:

1. Obtain the tobacco use declaration form: Contact your healthcare provider, insurance company, or employer to request a copy of the tobacco use declaration form. It may also be available online for download.
2. Read the instructions: Carefully read the instructions provided with the form to understand the purpose of the declaration and the information you need to provide.
3. Provide personal information: Fill out the required fields with your personal information such as your full name, date of birth, address, and contact details. Ensure that all the information is accurate and up to date.
4. Declare tobacco use: Indicate your tobacco use status by checking the appropriate box. If you have never used tobacco, there may be a separate section to declare non-use.
5. Provide additional details: Some tobacco use declaration forms may require additional information. This can include the frequency and duration of tobacco use, types of tobacco products used, attempts to quit, or participation in cessation programs.
6. Sign and date the form: Confirm your declaration by signing and dating the form as specified. Be sure to follow any additional instructions related to signatures, such as obtaining witness signatures if required.

Who needs tobacco use declaration:

1. Healthcare recipients: Patients or individuals seeking medical treatment or insurance coverage may be required to fill out a tobacco use declaration to provide accurate information about their tobacco use habits. This information is important for healthcare professionals to assess health risks and make informed decisions regarding patient care.
2. Insurance applicants: When applying for health, life, or disability insurance, insurers may request a tobacco use declaration to accurately assess risk and determine premium rates. Tobacco use can significantly impact insurance coverage and cost, making the declaration essential for an accurate evaluation.
3. Employees or job applicants: Some employers may require employees or potential job applicants to fill out a tobacco use declaration. This can be part of a wellness program or to enforce workplace policies related to tobacco use.
4. Schools or educational institutions: Educational institutions may require students or parents/guardians to complete a tobacco use declaration as part of enrollment or participation in certain programs, ensuring a smoke-free and healthy environment for all students.

Note: The need for a tobacco use declaration may vary depending on the organization or situation. It is important to check the specific requirements of the requesting party to determine if a tobacco use declaration is necessary.

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