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Quit line FAX Referral Form Fax Number: 1-800-483-3114 PROVIDER INFORMATION: Fax Sent Date: / / Clinic Name: Health Care Provider: Contact Name: I am a HIPAA-Covered Entity (Please check one) Fax:
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Start by gathering all the necessary information you want to include in your fax. This may include the recipient's name, organization, and any important details or instructions.
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Fax number 1-800-483-3114 is a designated number for submitting documents via fax.
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Individuals or entities specified in the instructions for the form associated with fax number 1-800-483-3114 are required to file.
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