Get the free MA Quitworks Fax Form - Make Smoking History

Provider name (First)(Last)(First)(Last)Contact name(be specific to support referral tracking)Clinic/Organization name Address City Prostate (Fax)()Zip EmailQuitLine can provide nicotine replacement

How to fill out ma quitworks fax form

How to fill out ma quitworks fax form

1. Gather all necessary information including your personal details, tobacco use history, referral source, and reason for referral.
2. Download the MA QuitWorks Fax Referral form from the official website or request a form from your healthcare provider.
3. Fill out the form completely and accurately, making sure to provide all required information.
4. Fax the completed form to the fax number listed on the form, along with any additional documentation if required.
5. Wait for confirmation of receipt from the QuitWorks program.

Who needs ma quitworks fax form?

1. Individuals who want to participate in the QuitWorks program to receive support and resources for quitting tobacco use.
2. Healthcare providers who want to refer their patients to the QuitWorks program for assistance with quitting tobacco.

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What is ma quitworks fax form?

The ma quitworks fax form is a form used to report information about an employee quitting their job.

Who is required to file ma quitworks fax form?

Employers are required to file the ma quitworks fax form when an employee quits their job.

How to fill out ma quitworks fax form?

To fill out the ma quitworks fax form, employers must provide information about the employee who is quitting, the reason for quitting, and the last day of work.

What is the purpose of ma quitworks fax form?

The purpose of the ma quitworks fax form is to help track employee separations and unemployment claims.

What information must be reported on ma quitworks fax form?

Information such as the employee's name, last day of work, reason for quitting, employer contact information, and any additional details must be reported on the ma quitworks fax form.