Get Quitline Fax Eng Only.doc

Filling out the Quitline Fax ENG Only.doc is a straightforward process that enables users to enroll in the Illinois Tobacco Quitline smoking cessation program. This guide provides comprehensive, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the Quitline Fax form online.

1. Click ‘Get Form’ button to access the Quitline Fax ENG Only.doc and open it in your document editor.
2. Begin by entering your first name and last name in the designated fields for patient information. Ensure that these details are accurate.
3. Fill in your mailing address, city or county, state, and ZIP code to provide a complete address for correspondence.
4. Please include your email address and phone number in the appropriate sections. Make sure to provide a phone number where you can be reached.
5. Indicate whether you are pregnant by checking the corresponding box if applicable.
6. Answer the questions about Medicaid/SCHIP by marking 'Yes' or 'No' as it applies to your situation.
7. If you have an alternate phone number, include it in the specified field. Additionally, indicate whether you prefer to receive messages.
8. Select your language preference by circling one of the options provided: English, Spanish, or another language you may specify.
9. Choose a suitable time for the Quitline to call you back by circling your preferred hours.
10. Read and understand the authorization section. Sign the form, including your printed name if you are signing on behalf of the patient, and the date.
11. For healthcare professionals, complete the tobacco treatment checklist by indicating the patient’s readiness to quit and any assessments on tobacco use.
12. Fill in the clinic name, phone number, and fax number where relevant, and ensure the clinic personnel signs the form.
13. After completing all sections of the form, review it for accuracy and completeness. You can then save your changes, download the document, print it, or share it as needed.

Start completing your Quitline Fax form online today to take the first step towards quitting tobacco.