Get the free Tobacco Cessation Referral Form

Complete this Tobacco Cessation Referral Form to connect individuals with cessation services in Lucas County. Submit via fax or email for assistance.

How to fill out tobacco cessation referral form

How to fill out tobacco cessation referral form

1. Gather all necessary information about the patient's tobacco use history.
2. Make sure you have the latest version of the tobacco cessation referral form.
3. Fill out the patient's personal information such as name, date of birth, and contact details.
4. Document the patient's tobacco use history including frequency, duration, and amount of tobacco use.
5. Indicate the reason for referral to the tobacco cessation program.
6. Obtain necessary signatures from the patient and healthcare provider.
7. Submit the completed form to the appropriate department for processing.

Who needs tobacco cessation referral form?

1. Individuals who are looking to quit tobacco use and need assistance from a tobacco cessation program.
2. Healthcare providers who are referring their patients to a tobacco cessation program for support and resources.

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What is tobacco cessation referral form?

A tobacco cessation referral form is a document used to refer individuals who wish to quit tobacco use to appropriate cessation resources or programs.

Who is required to file tobacco cessation referral form?

Healthcare providers, organizations, or agencies that identify individuals using tobacco and provide cessation services are typically required to file a tobacco cessation referral form.

How to fill out tobacco cessation referral form?

To fill out a tobacco cessation referral form, complete the required fields with the individual's personal information, details about their tobacco use, and information about the referral to cessation services.

What is the purpose of tobacco cessation referral form?

The purpose of the tobacco cessation referral form is to facilitate access to resources and support for individuals looking to quit tobacco use, ensuring they receive the assistance they need.

What information must be reported on tobacco cessation referral form?

The form typically requires the individual's name, contact information, tobacco use history, and the details of the referral organization or program.