Get the free QuitLine Fax-to-Quit Referral Form (English)

Name: Fillable Online QuitLine Fax-to-Quit Referral Form (English) Fax Email Print - pdfFiller
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COLORADO OUTLINE FAX Format to: 18002616259 Use this form to refer individuals who are ready to quit tobacco or thinking about quitting to the Colorado Outline for free support. PROVIDER INFORMATION

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

01

Obtain the quitline fax-to-quit referral form from the designated source.

02

Fill out the patient's demographic information, including name, address, phone number, and date of birth.

03

Provide details about the patient's tobacco use history, such as the number of cigarettes smoked per day and for how long.

04

Include information about any previous quit attempts and the methods used.

05

Indicate the reason for referral to the quitline program.

06

Sign and date the form before faxing it to the appropriate quitline number.

Who needs quitline fax-to-quit referral form?

01

Individuals who want to quit smoking or using tobacco products.

02

Healthcare providers who are referring patients to a quitline program for support in quitting.

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What is quitline fax-to-quit referral form?

The quitline fax-to-quit referral form is a document used to refer individuals to quitline services through fax for smoking cessation.

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

Healthcare providers and organizations assisting individuals with smoking cessation are required to file the quitline fax-to-quit referral form.

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

The form can be filled out by providing the necessary information about the individual being referred, including contact information, smoking history, and reason for referral.

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

The purpose of the quitline fax-to-quit referral form is to facilitate the referral process for individuals seeking assistance with quitting smoking.

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

Information such as the individual's name, contact information, smoking history, and reason for referral must be reported on the quitline fax-to-quit referral form.

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