Get the free Quitline FAX Referral Form - Moda Health

Referral Form Information collected by the Quit line will be treated confidentially and will not be released to other entities unless required by law. Client/patient details Given names:Surname’M

How to fill out quitline fax referral form

How to fill out quitline fax referral form

1. Obtain a quitline fax referral form either by downloading it from the official quitline website or by requesting it from the quitline program.
2. Start by providing the necessary contact information of the patient, such as their name, address, and phone number.
3. Indicate the preferred method of contact, such as phone or email.
4. Fill in the healthcare provider information, including their name, practice name, address, and phone number.
5. Specify the reason for the referral, such as a smoking cessation program.
6. Provide any relevant medical information about the patient, such as current medications or health conditions.
7. If applicable, include any additional notes or comments that may be useful for the quitline program.
8. Double-check all the information filled out on the form for accuracy and completeness.
9. Once completed, submit the quitline fax referral form to the designated fax number provided by the quitline program.

Who needs quitline fax referral form?

1. The quitline fax referral form is typically required by healthcare providers or professionals who want to refer patients to a quitline program.
2. These healthcare professionals can include doctors, nurses, pharmacists, counselors, or any other licensed healthcare provider who wishes to help their patients quit smoking or tobacco use.
3. The form is used to initiate contact between the healthcare provider and the quitline program, enabling the patient to receive support and resources to quit smoking successfully.

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What is quitline fax referral form?

The quitline fax referral form is a document used to refer individuals to a quitline service for help with quitting smoking.

Who is required to file quitline fax referral form?

Healthcare providers, counselors, and other professionals who work with individuals trying to quit smoking are required to file quitline fax referral forms.

How to fill out quitline fax referral form?

To fill out the quitline fax referral form, provide basic information about the individual being referred, including contact information and smoking history.

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 resources and support provided by a quitline service.

What information must be reported on quitline fax referral form?

The quitline fax referral form must include the individual's name, contact information, smoking history, and any relevant medical history.