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Fax to: 18002616259PATIENT FAX REFERRAL FORM Today's Date ___Use this form to refer patients who are ready to quit tobacco in the next 30 days to the Michigan Tobacco Quit line.PROVIDER(S): Complete

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This form is used to request a referral for a patient via fax.

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Healthcare providers or facilities who need to refer a patient to another provider.

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The form typically requires information about the patient, the referring provider, the receiving provider, and the reason for the referral.

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The purpose is to facilitate the process of referring a patient to another healthcare provider.

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Patient information, referring provider information, receiving provider information, and reason for referral.

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