Get the free MA Quitworks Fax Form

If a patient is interested in quitting tobacco, fill out this form with them and FAX/SEND to 18665609113. Feedback reports sent to provider as noted below. The Massachusetts Quit line offers free

How to fill out ma quitworks fax form

How to fill out ma quitworks fax form

1. Obtain the MA Quitworks fax form from the Quitworks website or program provider.
2. Fill in your personal information such as name, address, and contact number.
3. Provide details about your smoking history and current smoking habits.
4. Include any relevant health information that may be required on the form.
5. Sign and date the form to certify the information provided is accurate.
6. Fax the completed form to the designated fax number as specified on the form.

Who needs ma quitworks fax form?

1. Individuals who are seeking support and resources to quit smoking in Massachusetts.
2. Healthcare providers who are assisting their patients in smoking cessation.
3. Employers who are participating in smoking cessation programs for their employees.

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What is ma quitworks fax form?

The ma quitworks fax form is a document used to notify the Massachusetts Department of Unemployment Assistance when an employee quits their job.

Who is required to file ma quitworks fax form?

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

How to fill out ma quitworks fax form?

The ma quitworks fax form can be filled out online or by downloading and mailing a paper form to the Massachusetts Department of Unemployment Assistance.

What is the purpose of ma quitworks fax form?

The purpose of the ma quitworks fax form is to provide information to the Department of Unemployment Assistance so they can process unemployment claims for the employee who quit.

What information must be reported on ma quitworks fax form?

The ma quitworks fax form requires information such as the employee's name, social security number, last working day, and reason for quitting.