Get the free Quitline FAX Referral Form - Oregon

DATE FAX SENT CLINIC NAME CLINIC ZIP CODE HEALTH CARE PROVIDER CONTACT NAME FAX NUMBER am a HIPAA covered entity (please check one):YES PHONE NUMBERNODONT Inpatient Information: PATIENT NAME DATE

How to fill out quitline fax referral form

How to fill out quitline fax referral form

1. To fill out a quitline fax referral form, follow these steps:
2. Obtain a copy of the quitline fax referral form.
3. Fill in the necessary personal information, such as your name, contact details, and date of birth.
4. Provide information about your tobacco use history, including how long you have been smoking or using tobacco products.
5. Answer questions about your previous quit attempts, including any methods or medications used.
6. Indicate your preferred method of contact for follow-up support.
7. Specify if there are any additional notes or specific concerns you would like the quitline to address.
8. Review the completed form for accuracy and completeness.
9. Sign and date the referral form.
10. Fax the completed form to the designated quitline fax number.

Who needs quitline fax referral form?

1. The quitline fax referral form is needed by individuals who wish to seek support and assistance from a quitline service to quit tobacco use.
2. This form is typically used by individuals who want to access resources, counseling, and personalized quit plans offered by quitline services.

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What is quitline fax referral form?

Quitline fax referral form is a document used to refer individuals to a smoking cessation hotline via fax.

Who is required to file quitline fax referral form?

Healthcare providers, counselors, or other professionals who come into contact with individuals looking to quit smoking are required to file the quitline fax referral form.

How to fill out quitline fax referral form?

The quitline fax referral form typically requires information about the individual seeking help to quit smoking, such as their contact information, smoking history, and reasons for wanting to quit.

What is the purpose of quitline fax referral form?

The purpose of the quitline fax referral form is to facilitate the referral of individuals seeking help to quit smoking to a smoking cessation hotline for support and guidance.

What information must be reported on quitline fax referral form?

The quitline fax referral form may require information such as the individual's name, contact information, smoking history, current smoking habits, and reasons for wanting to quit.