Get the free Fax-to-Quit Fax Referral Form - CUNY - cuny

New York State Smokers' Quit line 1-866-NY-QUITS (1-866-697-8487) Referral Form Step-by-Step: Refer-to-Quit Fax form to: 1-866-QUIT-FAX (1-866-784-8329) Code: CUNY2012 If a tobacco user would like

How to fill out fax-to-quit fax referral form

To fill out the fax-to-quit fax referral form, follow these steps:

1. Start by entering your personal information, including your full name, address, and contact details.
2. Next, provide the necessary information related to your current employment, such as your job title, company name, and supervisor's name.
3. Fill in the reason for your referral, which could be due to resignation, termination, or any other relevant circumstances.
4. Make sure to include the date of when you want the referral faxed and any specific instructions or additional details.
5. Finally, sign and date the form, confirming that the information provided is accurate, and you understand the consequences of the fax referral.

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What is fax-to-quit fax referral form?

The fax-to-quit fax referral form is a document used to refer individuals who want to quit smoking to appropriate cessation services through fax communication.

Who is required to file fax-to-quit fax referral form?

Healthcare providers or organizations that want to refer individuals to smoking cessation services are required to file the fax-to-quit fax referral form.

How to fill out fax-to-quit fax referral form?

To fill out the fax-to-quit fax referral form, healthcare providers should provide the required information about the individual being referred, including their contact details, smoking history, and any relevant medical information.

What is the purpose of fax-to-quit fax referral form?

The purpose of the fax-to-quit fax referral form is to facilitate the referral process for individuals seeking assistance with smoking cessation, ensuring a streamlined communication between healthcare providers and cessation services.

What information must be reported on fax-to-quit fax referral form?

The fax-to-quit fax referral form should include the individual's name, contact information, smoking history, relevant medical information, and any specific requirements or preferences for cessation services.