Get Tobacco Quitline Referral Form - State Of Michigan - Michigan

The Tobacco Quitline Referral Form is designed for health providers to refer individuals who are ready to quit tobacco to the Michigan Tobacco Quitline. This guide will provide a clear step-by-step approach on how to complete this form effectively online.

Follow the steps to fill out the Tobacco Quitline Referral Form online.

1. Press the ‘Get Form’ button to retrieve the Tobacco Quitline Referral Form and open it in your preferred online editor.
2. In the 'Provider(s)' section, fill in your name as the provider, your contact name, and the name of your clinic, hospital, or department. Ensure you provide accurate details about your practice.
3. Provide your email address, physical address, and phone number. This information is essential for effective communication between you, the patient, and the Quitline.
4. Indicate whether the patient has any specified medical conditions by checking the appropriate boxes. If the patient has conditions such as pregnancy, uncontrolled high blood pressure, or heart disease, remember to provide your signature to authorize the dispensing of medication.
5. In the 'Patient' section, have the patient fill out their details, starting with their name, date of birth, and address. Ensure that all information is accurate and legible.
6. Ask the patient to select their preferred times for a Quitline coach to contact them, marking the relevant boxes for morning, afternoon, evening, or weekend.
7. Determine if the patient is hearing impaired and needs assistance. This is an important consideration for ensuring effective communication.
8. Collect the patient's consent by having them sign the form. This indicates that they are ready and willing to be referred to the Quitline.
9. Once all sections are completed, review the form for accuracy. Save any changes if needed, and prepare to submit the completed form by faxing it to 1-800-261-6259 or mailing to the specified address.

Complete the Tobacco Quitline Referral Form online to facilitate support for those ready to quit tobacco.