Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing provider information. Fill in the clinic name and its zip code, followed by identifying the health care provider and their contact name. Ensure the fax number and phone number are correctly entered.
3. Indicate whether you are a HIPAA covered entity by selecting 'Yes', 'No', or 'Don’t know'. This step is vital for compliance with privacy regulations.
4. In the patient information section, enter the patient’s name, date of birth, and gender. Fill in the patient's address, city, and zip code while providing primary and secondary phone numbers as applicable.
5. Select the language preference by checking the appropriate box next to English, Spanish, or Other.
6. If the patient is ready to quit tobacco, initial the consent for the Oklahoma Tobacco Helpline to contact them regarding their quit plan. Note that by not initialing the 'Do Not' permission, you allow them to leave a message.
7. Obtain the patient’s signature and date the form appropriately to validate the document.
8. Lastly, indicate the best 3-hour time frame for the Helpline to contact the patient and ensure to check the preferred contact method (primary or secondary number).
9. Once all sections are filled out completely, save your changes, and you may also choose to download, print, or share the completed form.

Complete the Oklahoma Helpline Fax Referral Form online today to take a step toward a healthier future.