WV Tobacco Quitline Fax-to-Quit Referral Form 2015-2025 free printable template

FAXTOQUIT REFERRAL FORM Fax Completed Form to: 18669004833 Todays Date Use this form to refer patients who are ready to quit tobacco in the next 30 days.PROVIDER(S): Complete this section, please

How to fill out referral form - nysmokecom

How to fill out WV Tobacco Quitline Fax-to-Quit Referral Form

1. Obtain the WV Tobacco Quitline Fax-to-Quit Referral Form.
2. Fill in the patient's personal information, including name, address, and contact details.
3. Indicate the patient’s tobacco use history, including type and frequency of tobacco products used.
4. Provide information about the patient's willingness to quit and any previous cessation attempts.
5. Complete the referring provider's information, including name, contact details, and signature.
6. Double-check all entered information for accuracy and completeness.
7. Fax the completed form to the WV Tobacco Quitline number provided on the form.

Who needs WV Tobacco Quitline Fax-to-Quit Referral Form?

1. Individuals who are smokers or tobacco users looking to quit.
2. Healthcare providers who want to refer patients to the Quitline for support.
3. Organizations or programs aiming to assist people in their tobacco cessation efforts.

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What is WV Tobacco Quitline Fax-to-Quit Referral Form?

The WV Tobacco Quitline Fax-to-Quit Referral Form is a document that healthcare providers use to refer individuals who want to quit smoking or using tobacco products to the West Virginia Tobacco Quitline for support and resources.

Who is required to file WV Tobacco Quitline Fax-to-Quit Referral Form?

Healthcare providers, including doctors, nurses, and other medical professionals, are required to file the WV Tobacco Quitline Fax-to-Quit Referral Form on behalf of patients who wish to receive assistance in quitting tobacco.

How to fill out WV Tobacco Quitline Fax-to-Quit Referral Form?

To fill out the WV Tobacco Quitline Fax-to-Quit Referral Form, providers need to complete sections including patient information, contact details, referral type, and any specific notes or instructions. Once completed, the form should be faxed to the designated Quitline number.

What is the purpose of WV Tobacco Quitline Fax-to-Quit Referral Form?

The purpose of the WV Tobacco Quitline Fax-to-Quit Referral Form is to streamline the referral process for individuals seeking help to quit tobacco, ensuring they receive prompt and effective support from the Quitline services.

What information must be reported on WV Tobacco Quitline Fax-to-Quit Referral Form?

The information that must be reported on the WV Tobacco Quitline Fax-to-Quit Referral Form includes the patient's name, contact information, tobacco use history, reasons for quitting, and the healthcare provider's contact details.