Get the free ashline referral form - azdhs

FAX TO: Arizona Smokers Helpline 1-866-897-1263 TODAY S DATE: / / Type of Setting: FAX BACK #: () Physician Office WIC Referred by: Dental Office STEP Local Project Location/Site: Health Clinic Healthline

How to fill out ashline referral form

Point by point guide on how to fill out the Ashline referral form and who needs it:

1. Visit the Ashline website: Go to the official Ashline website to find the referral form. It is usually located under the "Resources" or "Get Help" section of the website.
2. Familiarize yourself with the information required: Take a moment to review the information or documentation needed to complete the referral form. This may include personal details, contact information, and relevant medical history, depending on the purpose of the referral.
3. Gather necessary documents: Ensure that you have all the required documents readily available. This may include identification documents, medical records, or any other supporting paperwork that may be requested on the referral form.
4. Fill in personal details: Start by providing your personal information, including your full name, date of birth, address, and contact details. Make sure to double-check the accuracy of the information before moving on to the next section.
5. Indicate the purpose of the referral: Specify why you are seeking a referral through Ashline. This could be for smoking cessation support, counseling services, or any other relevant program offered by Ashline.
6. Answer additional questions: The referral form may include sections with specific questions related to your situation. Answer them accurately and to the best of your knowledge.
7. Provide any necessary supporting information: If the referral form requires additional information, such as medical history or previous treatment details, provide the requested details as accurately as possible. Include any relevant attachments or documentation if required.
8. Review and submit: Before submitting the completed form, carefully review all the information provided to ensure its accuracy and completion. Make any necessary amendments or additions before submitting.

Who needs the Ashline referral form?

1. Individuals seeking support to quit smoking: The Ashline referral form is primarily designed for individuals who are looking for assistance in quitting smoking. If you are a smoker and want to avail of services such as counseling, nicotine replacement therapy, or other support programs, you may need to fill out this form.
2. Healthcare professionals or organizations referring patients: The referral form may also be used by healthcare professionals or organizations who wish to refer their patients to Ashline for smoking cessation or related services. This allows healthcare providers to collaborate with Ashline and provide comprehensive support to their patients.
3. Friends or family members supporting a loved one in quitting smoking: If you are a friend or family member of someone who is trying to quit smoking and want to help them access Ashline's services, you can fill out the referral form on their behalf.

In conclusion, the Ashline referral form is essential for anyone seeking smoking cessation support, including individuals, healthcare professionals, and supportive friends or family members. By following the step-by-step guide provided above, you can accurately complete the form and get the necessary assistance from Ashline.

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What is ashline referral form?

The ashline referral form is a document used to refer individuals to the Arizona Smokers' Helpline for smoking cessation support.

Who is required to file ashline referral form?

Healthcare professionals, employers, family members, and individuals themselves can all file an ashline referral form.

How to fill out ashline referral form?

The ashline referral form can be filled out online on the Arizona Smokers' Helpline website or by calling their hotline.

What is the purpose of ashline referral form?

The purpose of the ashline referral form is to provide support and resources to individuals who want to quit smoking.

What information must be reported on ashline referral form?

The ashline referral form typically requires information such as the individual's contact information, smoking habits, and reasons for wanting to quit.