Get the QuitLine Fax-to-Quit Referral Form - Tobacco Free Colorado

Name: Fillable Online QuitLine Fax-to-Quit Referral Form - Tobacco Free Colorado Fax Email Print - pdfFiller
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CONNECTICUT OUTLINE FAX REFERRAL FORM Fax Number: 18004833114 FAX SENT DATE: / / Provider Information: CLINIC BAROCLINIC ZIP TELEHEALTH CARE PROVIDERCONTACT NAME FAX NUMBERPHONE NUMBER IAM A HIPAA

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How to fill out quitline fax-to-quit referral form

01

Step 1: Obtain a copy of the quitline fax-to-quit referral form.

02

Step 2: Fill in the required information, such as the patient's name, date of birth, and contact details.

03

Step 3: Include information about the patient's smoking history, including how many cigarettes they smoke per day.

04

Step 4: Indicate the reason for referral, such as the patient's desire to quit smoking or their health conditions related to smoking.

05

Step 5: Provide any additional relevant information, such as the patient's preferred language or any specific support needs.

06

Step 6: Ensure all the information provided is accurate and legible.

07

Step 7: Submit the completed referral form to the appropriate quitline fax number.

Who needs quitline fax-to-quit referral form?

01

Anyone who wants to quit smoking and is seeking support from a quitline

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What is quitline fax-to-quit referral form?

The quitline fax-to-quit referral form is a document used to refer individuals to a quitline program to help them quit smoking.

Who is required to file quitline fax-to-quit referral form?

Healthcare providers and organizations that work with smokers are required to file the quitline fax-to-quit referral form.

How to fill out quitline fax-to-quit referral form?

To fill out the quitline fax-to-quit referral form, providers need to enter the patient's information and reason for referral, then fax it to the quitline program.

What is the purpose of quitline fax-to-quit referral form?

The purpose of the quitline fax-to-quit referral form is to connect individuals who want to quit smoking with resources and support to help them succeed.

What information must be reported on quitline fax-to-quit referral form?

The quitline fax-to-quit referral form must include the patient's name, contact information, smoking history, and reason for referral.

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