Get Tobacco Cessation: Quitline Fax Referral Form (nc Dhhs) - Communitycarenc

This guide will assist you in effectively completing the Tobacco Cessation: Quitline Fax Referral Form to help individuals seeking support in quitting tobacco. By following the step-by-step instructions, you will ensure that all necessary information is accurately provided.

Follow the steps to accurately fill out the Quitline Fax Referral Form.

1. Press the ‘Get Form’ button to access the Tobacco Cessation: Quitline Fax Referral Form. This will allow you to open the form in an appropriate online editor.
2. In the Referring Organization Information section, fill in the date the fax is sent, the name of your organization, and the county. Indicate whether your organization is a Hospital or Clinic.
3. Confirm your status as a HIPAA-Covered Entity by checking the appropriate box. If you prefer not to receive a Participant’s Outcome Report, indicate this by checking the respective box as well.
4. Provide the contact information for the person referring. Include the name and contact phone number.
5. In the Person Being Referred to Quitline section, enter the individual’s full name, date of birth (DOB), address, city, gender, and primary contact number including the type.
6. Specify if the person being referred is pregnant by checking ‘Yes’ or ‘No’.
7. Enter a back-up phone number along with the type for additional contact.
8. Select the language preference by checking the appropriate option: English, Spanish, or Other.
9. Initial the statement indicating readiness to quit tobacco use or that they have recently quit, and indicate whether permission is granted for QuitlineNC to leave a message.
10. Gather the signature of the person being referred, and date it in the provided section.
11. Check the best time for QuitlineNC to call, selecting one time slot from the options available for contact.
12. Review all entries for accuracy. Once completed, save your changes, download, print, or share the form as required.

Complete your Tobacco Cessation: Quitline Fax Referral Form online today for a supportive path to quitting tobacco.