Get Quitline Fax Referral Form - Ct.gov - Ct

Filling out the Quitline FAX Referral Form is an essential step for individuals seeking support in quitting tobacco. This guide provides clear and concise instructions to help users navigate through the form effectively and submit their referrals with ease.

Follow the steps to complete the Quitline FAX Referral Form

1. Press the ‘Get Form’ button to access the Quitline FAX Referral Form and open it in your preferred viewing application.
2. Enter the information about the healthcare provider in the designated fields. Fill in the clinic name, postal code, provider name, contact name, fax number, and phone number.
3. Indicate whether you are a HIPAA-covered entity by selecting one of the options: Yes, No, or I do not know.
4. Provide the patient's information, including their full name, date of birth, and gender, by checking either Male (M) or Female (F). Ensure the address and primary phone numbers are clearly written.
5. Specify the secondary phone number if applicable and indicate the patient's preferred language by marking one of the options listed.
6. Indicate the patient's readiness to quit tobacco by initialing the provided statement requesting contact from the Connecticut Quitline for support.
7. If applicable, initial to indicate whether you authorize the Quitline to leave a message upon contact. Remember, not initialing allows the Quitline to leave a message.
8. Fill in the date and ensure the participant signs the form at the indicated location.
9. Select the best time for the Quitline to call the participant from the options provided, keeping in mind the operating hours for support.
10. Once all sections are filled out, review the information for accuracy. Users can then save changes, download, print, or share the completed form as needed.

Complete your Quitline FAX Referral Form online today to take the first step toward quitting tobacco.