Get the free Quitline FAX Referral Form - CT.gov - ct

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How to fill out quitline fax referral form

How to fill out quitline fax referral form:

1. Start by entering the necessary personal information. This typically includes your full name, contact details such as phone number and address, and any other relevant identification details requested.
2. Next, provide information about your tobacco use history. This may include the number of cigarettes or tobacco products you consume per day, the duration of your tobacco use, and any previous attempts to quit smoking.
3. Fill in details about your healthcare provider. You may be asked to provide the name, contact information, and any other relevant details about the healthcare professional who referred you to the quitline.
4. In the "Reason for Referral" section, clearly state why you are seeking assistance from the quitline. You can mention your desire to quit smoking, any specific challenges or concerns you have, and any other relevant information that might help the quitline support you better.
5. Ensure that you provide accurate and up-to-date medical information. Some quitline fax referral forms may require you to disclose any medical conditions or medications you are currently taking. This information helps the quitline tailor their support to your specific needs.
6. If there is any additional information or special instructions required, make sure to read and follow them carefully. This may include attaching supporting documentation, signatures, or other relevant paperwork.

Who needs quitline fax referral form:

1. Individuals who are motivated to quit smoking or using tobacco products and are seeking professional support and assistance.
2. Healthcare providers who are referring their patients to the quitline for additional support in quitting smoking or tobacco use.
3. Family members or friends who have been authorized or requested to fill out the quitline fax referral form on behalf of someone who wants to quit smoking or using tobacco.

Please note that the specific requirements for obtaining and filling out quitline fax referral forms may vary depending on the quitline service and the region you are in. It is always advisable to refer to the specific instructions provided by the quitline to ensure accurate and complete submission of the form.

For pdfFiller’s FAQs

What is quitline fax referral form?

Quitline fax referral form is a document used to refer individuals to a smoking cessation hotline for support and resources.

Who is required to file quitline fax referral form?

Healthcare providers, employers, or individuals who want to refer someone to a smoking cessation hotline are required to file the quitline fax referral form.

How to fill out quitline fax referral form?

To fill out the quitline fax referral form, you need to provide the individual's contact information, smoking history, reason for referral, and any other relevant details.

What is the purpose of quitline fax referral form?

The purpose of the quitline fax referral form is to connect individuals who want to quit smoking with the necessary resources and support offered by a smoking cessation hotline.

What information must be reported on quitline fax referral form?

Information such as the individual's name, contact information, smoking history, reason for referral, and any other relevant details must be reported on the quitline fax referral form.

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