Get Quitline Iowa Fax Referral Form - Achieve Healthy Communities - Achievecommunities

Filling out the Quitline Iowa Fax Referral Form is a straightforward process that helps individuals take important steps toward quitting tobacco. This guide provides clear instructions on each section of the form to ensure users can complete it effectively.

Follow the steps to successfully fill out the Quitline Iowa Fax Referral Form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by filling out the 'Patient Information' section. Clearly print the patient's last and first name, as well as their date of birth. Select the appropriate gender by marking either 'M' or 'F'. The patient must indicate their readiness to quit tobacco by initialing the provided space.
3. The patient signature and date must be provided in the designated areas. This signature confirms the patient's consent to share information with their provider regarding their quitting progress.
4. Next, complete the address section with the patient's residential details including the street address, city, state (IA), and zip code. Ensure that the contact information including two phone numbers is accurately filled out, as well as the email address.
5. In the 'Best times to call' section, indicate when the patient prefers to be contacted. The language preference should also be marked as either English, Spanish, or another language as applicable.
6. Proceed to fill out the 'Provider Information' section. Clearly print the provider's name, contact name, and the clinic or department’s name.
7. Provide the provider's email address and detailed contact information, including the address and phone number alongside city, state, and zip code.
8. The provider must indicate their consent if the patient requires nicotine replacement therapy (NRT) by signing in the designated area.
9. Any additional comments can be added in the comments section for clarity or special notes.
10. Once all sections are completed, review the information for accuracy, then save changes, and use the fax number provided or mail the form to the appropriate address.

Take the first step toward a tobacco-free life by filling out the Quitline Iowa Fax Referral Form online today.