Get Coquitline

Filling out the Coquitline referral form is an essential step for individuals ready to quit tobacco. This guide will help you navigate each section of the form clearly and effectively, ensuring a smooth process.

Follow the steps to successfully complete the Coquitline form online.

1. Click ‘Get Form’ button to access the Coquitline referral form and open it in your document editor.
2. In the 'Provider(s)' section, fill out the required information, including the provider's name, contact name, clinic or hospital information, email, address, phone number, city, state, and zip code.
3. Indicate whether the patient has Medicaid by selecting either ‘Yes’ or ‘No’. If 'Yes', ensure to complete the Medicaid prior-authorization form on the back of the piece.
4. Check any relevant medical conditions that apply to the patient, such as pregnancy or heart disease. This information is crucial for determining the appropriate care.
5. Obtain the provider's signature to authorize the QuitLine to dispense nicotine replacement therapy, if applicable.
6. In the 'Patient' section, the patient should fill out their initial, date of birth, and indicate their readiness to quit smoking.
7. Specify the best time for the QuitLine to call and indicate if a message can be left.
8. Fill out insurance information, including the insurance company name and member ID, if applicable.
9. Provide the patient’s contact information, including phone numbers, email, and preferred language.
10. The patient must sign and date the form to confirm their participation in the QuitLine services.
11. Finally, submit the completed form by faxing it to the designated number or mailing it to the Colorado QuitLine address.

Complete your Coquitline form online to support your journey to quitting tobacco.