Get Smoking Cessation Program Referral - Jackson Health

Filling out the Smoking Cessation Program Referral form for Jackson Health is an important step towards quitting smoking. This guide will walk you through the process, ensuring that you complete each section accurately and effectively.

Follow the steps to complete your form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Enter the date of referral in the designated section. Make sure this reflects the current date or the date you are submitting the form.
3. Fill in the patient's name clearly. This should be the full name of the individual being referred to the program.
4. Provide the patient's address, including city and zip code. Ensure that this information is accurate for follow-up communications.
5. Input the patient's phone number for any necessary contact regarding the program.
6. Include the patient's medical record number (MRN), if applicable, to assist with referencing their health information.
7. Complete the section for the person or department that is making the referral. This includes the referrer’s name, department, phone number, and email address. This information is crucial for any necessary correspondence.
8. Confirm the patient's agreement to be referred to the UM-AHEC/JHS Quit Smoking Now Program by checking that the statement is clearly indicated.
9. Ensure the patient provides their signature and date, indicating their consent and agreement to the referral and information sharing.
10. Indicate the patient's readiness to quit by choosing one of the provided options: contemplation, action, maintenance, or relapse. This helps determine the appropriate support needed.
11. Select the patient's language preference from the options available: English, Spanish, or Creole to ensure clear communication.
12. Once all fields are completed, review the form for accuracy. You can then save changes, download, print, or share the completed form as required.

Complete the Smoking Cessation Program Referral form online today to take a significant step towards a healthier future.