Get the free Quit Fax Referral Form - The Yavapai-Apache Nation - yavapai-apache

FAX TO: Arizona Smokers Helpline 1-866-897-1263 TODAY S DATE: / / Location: Bavaria/Apache Nation 2400 West Days Street Camp Verde, Arizona 86322 FAX BACK #: (928)- 567-5452 Referred by: Location/Site:

How to fill out quit fax referral form

How to Fill out Quit Fax Referral Form:

1. Obtain the form: The quit fax referral form can usually be obtained from a healthcare provider, a tobacco cessation program, or an organization promoting smoking cessation.
2. Personal Information: Start by entering your personal information on the form. This typically includes your full name, contact information, and date of birth. Make sure to provide accurate information to ensure proper communication and follow-up.
3. Referral Source: Indicate the source of the referral, which could be a healthcare provider, a friend, a family member, or an organization. This helps the receiving party know how you were referred to them and may provide useful context for further assistance.
4. Reason for Referral: Specify the reason for the referral. For a quit fax referral form, it would usually be related to tobacco cessation or smoking cessation efforts. Briefly explain your motivation or goals behind wanting to quit smoking.
5. Preferred Method of Contact: Identify your preferred method of contact for receiving support or follow-up. This can include options such as phone, email, or text message.
6. Healthcare Provider Information: If applicable, provide information about your healthcare provider, including their name, practice or clinic name, contact information, and any other relevant details. This allows for better coordination between your healthcare provider and the organization or program receiving the referral.
7. Additional Comments: If there are any additional comments, concerns, or specific requests you would like to make, include them in this section. This may include scheduling preferences, special considerations, or any other pertinent information you think is important for the receiving party to know.

Who Needs Quit Fax Referral Form:

1. Individuals seeking tobacco cessation support: The quit fax referral form is primarily designed for individuals who want to quit smoking or use other tobacco products. It serves as a means of connecting them with appropriate resources and programs that can provide support and guidance.
2. Healthcare providers: Healthcare providers, such as doctors, nurses, or counselors, who work directly with individuals trying to quit smoking may use the quit fax referral form to connect their patients with additional resources. This allows for a more comprehensive approach to smoking cessation, combining medical guidance with specialized programs.
3. Tobacco cessation programs and organizations: Programs and organizations focused on tobacco cessation often utilize quit fax referral forms to facilitate communication and collaboration with healthcare providers and their patients. These forms provide a structured way to refer individuals to their services and ensure that the necessary support is provided.

Note: While the specific individuals who may need a quit fax referral form can vary depending on the context and specific program or organization, these are the general groups that typically use or benefit from such forms.

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What is quit fax referral form?

Quit fax referral form is a document used to refer individuals who are interested in quitting smoking to resources and support services.

Who is required to file quit fax referral form?

Healthcare professionals, community organizations, or employers who work with individuals who want to quit smoking may be required to file quit fax referral form.

How to fill out quit fax referral form?

The quit fax referral form typically requires basic information about the individual looking to quit smoking, such as their name, contact information, smoking history, and reason for wanting to quit.

What is the purpose of quit fax referral form?

The purpose of quit fax referral form is to connect individuals who want to quit smoking with resources and support services that can help them achieve their goal.

What information must be reported on quit fax referral form?

The quit fax referral form may require information such as the individual's smoking habits, any previous quit attempts, and their preferred methods of quitting.