Get the free philarefugeehealth.org08PA-Quitline-Referral-FormPATIENT FAX REFERRAL FORM - philare...
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PA FREE Quit line PATIENT FAX REFERRAL FORM Fax to: 18002616259 Todays Date ___ Fax referral to the PA FREE Quit line is for patients who are ready to quit in the next 30 days AN D ready to accept
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How to fill out philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form
How to fill out philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form
01
Start by downloading the philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form from the website.
02
Fill in the patient's personal information such as name, address, phone number, and date of birth.
03
Provide details about the patient's tobacco use history, including the number of cigarettes smoked per day and the duration of tobacco use.
04
Indicate any previous quit attempts and the methods used.
05
Mention any health conditions or medications that may be relevant to the patient's tobacco cessation journey.
06
Include your contact information and any additional notes or instructions for the recipient of the referral form.
07
Double-check all the information you have entered to ensure accuracy.
08
Fax the completed referral form to the specified fax number or deliver it in person to the appropriate healthcare provider.
Who needs philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form?
01
The philarefugeehealthorg08pa-quitline-referral-form patient fax referral form is needed for individuals who would like to refer patients to the quitline for tobacco cessation support. It is commonly used by healthcare providers, clinics, and other organizations involved in assisting individuals in quitting smoking or using other tobacco products.
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What is philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form?
The philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form is a document used for referring patients to a quitline service for support in quitting smoking.
Who is required to file philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form?
Healthcare providers or professionals who want to refer a patient to a quitline service are required to fill out and file the form.
How to fill out philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form?
The form typically requires information about the patient's demographics, smoking history, contact information, and consent for referral. Healthcare providers can fill out the form electronically or manually.
What is the purpose of philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form?
The purpose of the form is to facilitate the referral process of patients who want to quit smoking to a quitline service, where they can receive support and resources for tobacco cessation.
What information must be reported on philarefugeehealthorg08pa-quitline-referral-formpatient fax referral form?
The form typically requires information such as patient's name, contact information, smoking history, reason for referral, and healthcare provider's details.
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