Get the free connecticut quitline fax referral form - Stratford, CT

CONNECTICUT OUTLINE FAX REFERRAL FORM Fax Number: 18004833114 FEC HA DE ENVOY: ___/___/___Information Del provender DE services medicos: HOMBRE DE LA CLNICACDIGO POSTALNOMBRE DEL PROVEEDORNOMBRE DEL

How to fill out connecticut quitline fax referral

How to fill out connecticut quitline fax referral

1. Start by downloading the Connecticut Quitline Fax Referral form from the official website.
2. Fill out the patient information section with the required details such as their name, date of birth, address, and contact number.
3. Provide information about the referring healthcare provider including their name, NPI number, and contact information.
4. Specify the reason for referral and any relevant medical history or treatment information.
5. Indicate the preferred method of communication for follow-up and counseling.
6. If applicable, include any additional notes or comments that may be relevant to the referral.
7. Review the completed form to ensure all the necessary information is provided and accurate.
8. Fax the referral form to the designated Connecticut Quitline fax number provided on the form or on their official website.
9. Keep a copy of the fax transmission report for your records.

Who needs connecticut quitline fax referral?

1. Connecticut Quitline fax referral is needed by healthcare providers who are referring their patients to the Connecticut Quitline for smoking cessation support.
2. This referral is beneficial for individuals who want to quit smoking and require additional assistance or counseling.

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What is connecticut quitline fax referral?

Connecticut quitline fax referral is a form used to refer individuals to the state's quitline for assistance with smoking cessation.

Who is required to file connecticut quitline fax referral?

Healthcare providers and organizations are required to file connecticut quitline fax referral when referring patients or clients to the quitline.

How to fill out connecticut quitline fax referral?

To fill out connecticut quitline fax referral, providers need to include the patient's information, reason for referral, and their own contact information before faxing it to the quitline.

What is the purpose of connecticut quitline fax referral?

The purpose of connecticut quitline fax referral is to connect individuals who are interested in quitting smoking with the resources and support offered by the state's quitline.

What information must be reported on connecticut quitline fax referral?

Information such as patient demographics, smoking history, reason for referral, and provider contact information must be reported on connecticut quitline fax referral.