Get the free Tennessee Tobacco QuitLine Fax Referral/ConsentForm

Program: Baby & Me WIC Tenner/MCO Other Tennessee Tobacco Outline Fax Referral/Consent Form Complete and Fax this form to: 18006929023 or Email to: referrals iqhquitline.com (for additional copies

How to fill out tennessee tobacco quitline fax

How to fill out tennessee tobacco quitline fax

1. To fill out the Tennessee Tobacco Quitline fax, follow these steps:
2. Start by entering the date on the designated space.
3. In the 'Referring Provider' section, fill in the required information such as name, address, and contact details.
4. Indicate the patient's information including name, date of birth, and contact information in the 'Patient Information' section.
5. Tick the appropriate box to select the reason for referral (e.g., tobacco cessation counseling, nicotine replacement therapy, etc.).
6. Specify any relevant medical conditions and medications in the 'Medical Information' section.
7. If necessary, include additional notes or comments in the 'Comments' field.
8. Make sure to sign the referral form and provide your contact information in case the Tennessee Tobacco Quitline staff needs further clarification.
9. Double-check all the provided information for accuracy and completeness.
10. Fax the completed form to the designated Tennessee Tobacco Quitline fax number.
11. Keep a copy of the fax for your records.

Who needs tennessee tobacco quitline fax?

1. The Tennessee Tobacco Quitline fax is needed by healthcare providers referring patients to the quitline for assistance in quitting tobacco use.
2. Typically, primary care physicians, healthcare clinics, hospitals, and other healthcare professionals utilize the Tennessee Tobacco Quitline fax for making referrals.
3. This form helps ensure a streamlined process of connecting patients interested in quitting tobacco with the necessary resources and support provided by the Tennessee Tobacco Quitline.

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What is tennessee tobacco quitline fax?

Tennessee tobacco quitline fax is a document used to report information related to tobacco cessation services provided by the state.

Who is required to file tennessee tobacco quitline fax?

Healthcare providers and organizations that offer tobacco cessation services in Tennessee are required to file tennessee tobacco quitline fax.

How to fill out tennessee tobacco quitline fax?

Tennessee tobacco quitline fax can be filled out online or by mail. The form typically requires information such as the number of tobacco users served, types of services provided, and outcomes of the services.

What is the purpose of tennessee tobacco quitline fax?

The purpose of tennessee tobacco quitline fax is to track and monitor the delivery of tobacco cessation services in Tennessee.

What information must be reported on tennessee tobacco quitline fax?

Information such as the number of tobacco users served, types of services provided, and outcomes of the services must be reported on tennessee tobacco quitline fax.