Get the free Quitline Iowa Fax Referral Form - ACHIEVE Healthy Communities - achievecommunities

Quit line Iowa Fax Form Fax to: 8002616259 Date PATIENT INFORMATION (PRINTCLEARLY) Patient name (Last), (First) Date of birth Gender M F I am ready to quit tobacco and request that Quit line Iowa

How to fill out quitline iowa fax referral

How to fill out quitline Iowa fax referral:

1. Obtain a copy of the quitline Iowa fax referral form. You may be able to find this form on the official quitline Iowa website or by contacting their support team.
2. Begin by filling out the requested personal information on the form. This typically includes your name, address, phone number, and email address.
3. Next, provide information about your tobacco usage. This can include details such as the type of tobacco products you use, how often you use them, and how long you have been using them.
4. Indicate your preferred method of contact on the form. This may include options such as phone, email, or text message.
5. If you have any additional comments or concerns, you can include them in the designated section of the form.
6. Once you have completed all the necessary sections of the form, double-check for any errors or missing information.
7. Finally, submit the filled-out quitline Iowa fax referral form via fax to the designated fax number provided on the form.

Who needs quitline Iowa fax referral:

1. Individuals who are seeking assistance in quitting tobacco use may benefit from the quitline Iowa fax referral.
2. People who are residents of Iowa and looking for support, advice, and resources to quit smoking or using other tobacco products can utilize this service.
3. This referral may be particularly useful for those who have tried quitting before but were unsuccessful and are in need of additional guidance and resources.

For pdfFiller’s FAQs

What is quitline iowa fax referral?

Quitline Iowa fax referral is a form used to refer individuals to the Quitline Iowa program for assistance with quitting smoking.

Who is required to file quitline iowa fax referral?

Healthcare providers, employers, and individuals can file a quitline Iowa fax referral.

How to fill out quitline iowa fax referral?

Quitline Iowa fax referral can be filled out online or by fax. Information such as the individual's name, contact information, and smoking history must be provided.

What is the purpose of quitline iowa fax referral?

The purpose of quitline Iowa fax referral is to help individuals access resources and support to quit smoking.

What information must be reported on quitline iowa fax referral?

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

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