Get Wisconsin Tobacco Quit Line Fax To Quit Consent Form - Ctri Wisc

This guide provides a comprehensive overview of how to effectively complete the Wisconsin Tobacco Quit Line Fax To Quit Consent Form. It is designed to assist users in navigating each section of the form with clarity and support.

Follow the steps to complete the form accurately and efficiently.

1. Select the ‘Get Form’ button to obtain the consent form and open it in your preferred editor.
2. Locate the Provider Information section. Fill in the Fax Sent Date using the format ___/___/___ and provide the Facility Name. Indicate if you are a HIPAA-Covered Entity by checking the appropriate box: Yes, No, or I don’t know.
3. Enter the Healthcare Provider's name along with their Address, City, Zip, and County. Fill in the Contact Name and provide the Fax and Phone numbers, along with the Email address.
4. In the Comments section, add any relevant information about the patient that may assist the Quit Line.
5. Move to the Patient Information section and print the patient's details. Include whether the patient is Pregnant by checking Yes or No.
6. Provide the Patient Name, DOB in the format ___/___/____, Address, and Phone Number. Optionally, add an Alternate Phone Number.
7. Select the Language Preference by checking English or Other and specifying if necessary.
8. Check the Tobacco Type that primarily reflects the patient's usage: Cigarettes, Chew/Spit, Cigar, or Pipe.
9. Indicate the patient's readiness to quit by initialing next to the statement expressing their request for contact from the Wisconsin Tobacco Quit Line.
10. Select the best times for the Quit Line to reach the patient within the next 72 hours by checking the available time slots.
11. Add any comments regarding the patient's availability in the provided space.
12. The patient is required to sign and date the bottom of the form where indicated.
13. After completing the form, ensure to save changes, download, print, or share the form as needed.

Complete the Wisconsin Tobacco Quit Line Fax To Quit Consent Form online to take the first step towards quitting tobacco.