Get Oregon Tobacco Quit Line Fax Referral Form - Www2 Massgeneral

Filling out the Oregon Tobacco Quit Line Fax Referral Form is a straightforward process that enables users to seek assistance with quitting tobacco. This guide will provide clear, step-by-step instructions for completing the form accurately and efficiently.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to access the Oregon Tobacco Quit Line Fax Referral Form online.
2. In the Provider Information section, fill in the fax sent date, clinic name, health care provider's name, contact name, and indicate if you are a HIPAA-Covered Entity by selecting yes, no, or I don’t know. Provide the fax number and phone number for the provider.
3. In the Client Information section, enter the client's gender, name, and date of birth. Indicate if the client is pregnant by checking yes or no, and provide the address, city, and zip code.
4. Include the primary and secondary phone numbers, specifying the type for each. Also, check the language preference from the options provided.
5. Select the types of tobacco used by checking all relevant options. Indicate readiness to quit tobacco by initialing the statement requesting assistance from the Oregon Tobacco Quit Line. If permission is not given to leave a message, initial the corresponding statement.
6. Obtain the client's signature and date the form. This is essential for verifying the request.
7. Specify the best 3-hour time frame for the Oregon Tobacco Quit Line to reach the client, recognizing the Quit Line's operating hours. Choose whether the contact should be made via the primary or secondary phone number.
8. Once all sections are filled out, review the form for accuracy. Save your changes, and proceed to download, print, or share the form as necessary.

Complete your documents online to obtain the support you need in quitting tobacco.