Get the free Community FAX-TO-QUIT Referral template

APPLICATION FOR INVESTMENT180 Association Dr Charleston, West Virginia 25311 Telephone: 3043456200 Email: WVJITInfo@wv.govDate of Application: ___/___/___Applicant Information:Firm Name:___DBA:___Mailing

How to fill out community fax-to-quit referral template

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

1. Obtain a copy of the community fax-to-quit referral form from your local healthcare provider or tobacco cessation program.
2. Fill out your personal information including name, contact information, and any relevant health history.
3. Provide information about your smoking habits, including how many cigarettes you smoke per day and any previous attempts to quit.
4. Sign the form to give consent for the referral to be sent to the tobacco cessation program.
5. Return the completed form to your healthcare provider or program for them to fax it to the appropriate tobacco cessation program.

Who needs community fax-to-quit referral form?

1. Individuals who are looking to quit smoking and are seeking support and resources from a tobacco cessation program.

What is Community FAX-TO-QUIT Referral Form?

The Community FAX-TO-QUIT Referral is a Word document required to be submitted to the specific address in order to provide some information. It needs to be filled-out and signed, which can be done in hard copy, or with the help of a particular software e. g. PDFfiller. This tool lets you fill out any PDF or Word document right in the web, customize it depending on your purposes and put a legally-binding electronic signature. Once after completion, user can send the Community FAX-TO-QUIT Referral to the appropriate receiver, or multiple ones via email or fax. The editable template is printable as well thanks to PDFfiller feature and options presented for printing out adjustment. In both electronic and physical appearance, your form will have got clean and professional outlook. You may also save it as the template to use later, without creating a new file again. You need just to customize the ready template.

Instructions for the form Community FAX-TO-QUIT Referral

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What is community fax-to-quit referral form?

The community fax-to-quit referral form is a document used to refer individuals who wish to quit tobacco use to cessation resources and support services.

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

Healthcare providers and organizations that assist individuals in quitting tobacco use are typically required to file the community fax-to-quit referral form.

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

To fill out the community fax-to-quit referral form, complete the necessary sections, including patient information, contact details, and specific cessation services requested, and then fax it to the appropriate cessation program.

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

The purpose of the community fax-to-quit referral form is to streamline the referral process for individuals seeking help to quit tobacco by ensuring they are connected with supportive resources.

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

The information that must be reported on the community fax-to-quit referral form typically includes the individual's name, contact information, smoking history, and the specific cessation resources being requested.