Get Quitline Fax Referral Form - Nc Bcccp Home

This guide provides a comprehensive overview of how to accurately complete the Quitline Fax Referral Form for the NC BCCCP program online. By following these steps, you will ensure that all necessary information is submitted for a smooth referral process.

Follow the steps to complete the form online with ease.

1. Press the ‘Get Form’ button to obtain the Quitline Fax Referral Form and open it in your chosen editor.
2. Fill in the 'Referring Organization Information' section. Circle either 'BCCCP' or 'NC WISEWOMAN' to indicate which program you are referring the participant to. Enter the organization name and specify if it is a hospital, clinic, agency, or county.
3. Indicate your status as a HIPAA-Covered Entity by checking the appropriate box. If you do not wish to receive a Participant’s Outcome Report, please also check that box. Enter the fax number for your organization.
4. Complete the 'Person Referring' section by writing your name and contact phone number.
5. In the 'Person Being Referred to Quitline' section, fill in the participant’s name, date of birth, address, city, and zip code.
6. Specify the participant's gender by selecting 'Male' or 'Female.' Input the best number to call and any backup number, indicating the type for each (home, work, or cell).
7. Select the participant's language preference by checking 'English,' 'Spanish,' or 'Other' and providing additional details if necessary.
8. Initial the statement indicating the participant's readiness to quit tobacco use. If the participant does not wish to receive messages when contacted, initial that option as well.
9. Obtain the participant's signature and date of signing.
10. Choose the best time for QuitlineNC to call the participant by checking one of the provided time options.
11. Once all sections are completed, review the form for accuracy. Save your changes, download, print, or share the completed form as needed.

Start filling out the Quitline Fax Referral Form online today to help support your referral process.