Get Oklahoma Helpline Fax Referral Form

Filling out the Oklahoma Helpline Fax Referral Form online is a straightforward process that ensures your information is communicated effectively. This guide will walk you through each section of the form, providing clear instructions to help you complete it accurately.

Follow the steps to fill out the form with ease.

1. Click the ‘Get Form’ button to acquire the form and open it in your preferred editing platform.
2. Begin by completing the Provider Information section. Include the clinic name, ZIP code, and the health care provider’s details, specifying whether the provider is a physician, nurse, or clinic staff. Also, add the contact name, fax number, and phone number provided for further communication.
3. Indicate whether you are a HIPAA covered entity by checking one of the options: Yes, No, or Don’t know.
4. Proceed to the Patient Information section where you will fill in the patient’s gender, name, date of birth, and complete address, including city and ZIP code.
5. Choose the primary phone number type (home, work, or cell) and include the number. Also, if applicable, provide a secondary phone number following the same format.
6. Select the language preference for communication by marking one of the options: English, Spanish, or Other.
7. Indicate your readiness to quit tobacco by initialing the box next to the corresponding statement. Also, select whether you permit the Oklahoma Tobacco Helpline to leave a message when reaching out.
8. Have the patient sign and date the form, confirming the information provided.
9. Select the best 3-hour time frame for the Oklahoma Tobacco Helpline to contact the patient. Make sure to check the preferred time frame and corresponding phone number type for the follow-up call.
10. Finally, review all entries for accuracy before saving changes, downloading, printing, or sharing the completed form.

Complete your Oklahoma Helpline Fax Referral Form online today to get the assistance you need.