Get the free Quitline FAX Referral Form - oregon.gov

Oregon Tobacco Quit Line Fax Referral Form Fax Number: 18004833114Provider Information:FAX SENT DATE: / / NAME OF CLINIC, PRACTICE, PHARMACY OR HOSPITALCLINIC ZIP CODEREQUIRED: I AM A HIPAA COVERED

How to fill out quitline fax referral form

How to fill out quitline fax referral form

1. To fill out the quitline fax referral form, follow these steps:
2. Start by entering your personal information, such as your name, address, and contact details.
3. Provide information about the patient for whom you are making the referral. This includes their name, date of birth, gender, and contact information.
4. Indicate the reason for the referral and provide any relevant medical history or current treatment information.
5. Specify the preferred method of communication and any additional comments or instructions.
6. Finally, review the form to ensure all the information is accurate and complete. Sign and date the form before submitting it via fax to the designated quitline number.

Who needs quitline fax referral form?

1. Any healthcare professional or organization who wishes to refer a patient to a quitline program may need the quitline fax referral form. This form is commonly used by physicians, nurses, counselors, and other healthcare providers who want to connect their patients with smoking cessation resources and support available through the quitline.

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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 for smoking cessation services.

Who is required to file quitline fax referral form?

Healthcare providers, counselors, or other professionals who are assisting individuals in quitting smoking may be required to file the quitline fax referral form.

How to fill out quitline fax referral form?

The quitline fax referral form can be filled out by providing the necessary information about the individual being referred, including contact information and reasons for the referral.

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 available through a quitline service.

What information must be reported on quitline fax referral form?

The quitline fax referral form typically requires information such as the individual's name, contact information, smoking history, and reasons for seeking help.