Get the free Tobacco Quitline FAX Referral Form - Oregon.gov

HAWAII TOBACCO OUTLINE FAX REFERRAL FORM Fax Number: 18004833114 FAX SENT DATE: / / Provider Information: CLINIC BAROCLINIC ZIP TELEHEALTH CARE PROVIDERCONTACT NAME FAX NUMBERPHONE NUMBERLESS AM A

How to fill out tobacco quitline fax referral

How to fill out tobacco quitline fax referral

1. To fill out a tobacco quitline fax referral, follow these steps:
2. Obtain a tobacco quitline fax referral form from the quitline provider.
3. Fill out the patient's personal information, including their name, contact information, and date of birth.
4. Provide details about the patient's tobacco use history, such as the number of cigarettes smoked per day and the duration of tobacco use.
5. Indicate the reason for the referral, such as a desire to quit smoking or health concerns related to tobacco use.
6. Include any relevant medical or personal notes about the patient that may be helpful for the quitline provider.
7. Obtain the patient's consent to share their information with the quitline provider.
8. Submit the completed fax referral form to the designated fax number provided by the quitline provider.
9. Follow up with the quitline provider if necessary to ensure the referral has been received and processed.

Who needs tobacco quitline fax referral?

1. Anyone who is interested in quitting tobacco use can benefit from a tobacco quitline fax referral.
2. This referral is especially helpful for individuals who may need additional support, counseling, or resources to successfully quit smoking or using other tobacco products.
3. Healthcare providers, social workers, and community organizations may also recommend a tobacco quitline fax referral for their patients or clients who want to quit tobacco use.

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What is tobacco quitline fax referral?

Tobacco quitline fax referral is a form used to refer individuals who are interested in quitting tobacco use to a quitline service for assistance.

Who is required to file tobacco quitline fax referral?

Healthcare providers, tobacco treatment specialists, and organizations promoting tobacco cessation are required to file tobacco quitline fax referral.

How to fill out tobacco quitline fax referral?

Tobacco quitline fax referral should be filled out with the individual's contact information, tobacco use history, and reason for seeking assistance with quitting.

What is the purpose of tobacco quitline fax referral?

The purpose of tobacco quitline fax referral is to connect individuals with resources and support to help them quit using tobacco.

What information must be reported on tobacco quitline fax referral?

Information such as the individual's name, contact information, tobacco use history, and reason for seeking assistance must be reported on tobacco quitline fax referral.