Get Fax-to-quit 1-800-quit-now Referral Form - Www2 Massgeneral

Filling out the FAX-TO-QUIT 1-800-QUIT-NOW Referral Form is a critical step in accessing tobacco cessation resources. This guide provides user-friendly instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the referral form.

1. Click ‘Get Form’ button to access the referral form and open it for editing.
2. Enter today’s date in the specified format (MM/DD/YYYY) for accurate record-keeping.
3. Provide the fax number where the referral will be sent by filling in the 'FAX BACK #' field.
4. In the 'Referred By' field, input the name of the person or organization making the referral.
5. Fill in the organization name under 'Organization' for proper identification.
6. Complete the address section including 'Address', 'City', and 'Zip' to ensure proper communication.
7. List a contact phone number in the 'Phone' field, ensuring accurate format.
8. Select the setting from which the referral is being made by checking the appropriate box: Physicians Office, Dentist Office, or Other Setting.
9. In the 'Patient Consent and Personal Information Section', acknowledge understanding of the Quitline's intent and the confidentiality of information provided.
10. Print the patient’s name in the designated area and include their phone number.
11. If applicable, obtain the patient or guardian's signature to confirm consent, and clarify the best time to call the participant.
12. Indicate the county of residence and list the insurance carrier for any necessary follow-up.
13. Choose whether or not messages may be left for the participant.
14. If the patient is enrolled in Medicaid, provide their ID number.
15. Select the language preference for communication by marking the appropriate box.
16. Ensure the provider signature is completed for accountability before submitting.
17. Once all sections are complete, save changes, download, or print the form for submission.

Complete your forms online today to access valuable tobacco quitting resources.