Get Fax Referral Form - Quitlinenc

Filling out the Fax Referral Form for QuitlineNC is a crucial step in providing support for individuals who wish to quit tobacco use. This guide will walk you through the process of completing the form online, ensuring that all necessary information is accurately captured.

Follow the steps to fill out the Fax Referral Form correctly.

1. Press the ‘Get Form’ button to obtain the Fax Referral Form and open it in your document editor.
2. Enter the date when the fax is being sent in the designated field. This helps to track the submission timeframe.
3. Fill in the organization name, specifying if you are a Hospital or Clinic in the corresponding section.
4. Indicate your county in the provided space to ensure accurate geographical recognition.
5. If applicable, check the box to confirm whether your organization is a HIPAA-Covered Entity. This is important for compliance with privacy regulations.
6. Provide the name and contact phone number of the person making the referral.
7. Fill in the details of the individual being referred to QuitlineNC, including their name, date of birth, address, city, and zip code.
8. Select the gender of the person being referred by marking the appropriate option.
9. Provide the best contact number for QuitlineNC to reach the person and select the type of number (home, work, or cell).
10. Fill in a backup contact number and specify its type as well.
11. Select the language preference from the options provided.
12. Initial the relevant section indicating the person’s readiness to quit tobacco within the next 30 days or if they have recently quit.
13. Initial the section if the individual does not want QuitlineNC to leave a message when contacting them.
14. Obtain a signature and date from the person being referred, confirming the information provided.
15. Select the best time for QuitlineNC to make a call, ensuring the preferences are clearly indicated.
16. Once all fields are completed, you can save changes to the document, download it, print a hard copy, or share it as needed.

Complete the Fax Referral Form online today to help someone take the important step toward quitting tobacco.