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Get Indiana Tobacco Quitline FAX Referral Form Fax Number: 1-800 ...

Indiana Tobacco Quitline FAX Referral Form Fax Number 1-800-483-3114 Fax Sent Date // Provider Information Clinic Name Health Care Provider Contact Name I am a HIPAA-Covered Entity Please check one Yes No I Don t Know Phone - Comments Patient Information Gender male / female Patient Name Address Primary Pregnant Y N Zip Secondary - Type HM WK CELL OTHER Language Preference check one English Spanish Other - Tobacco Type check ALL that apply Cigar....

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