Get Use This Form To Refer Patients Who Are Ready To Quit Tobacco In The Next 30 Days To Quit Now

This guide provides clear and detailed instructions on how to effectively fill out the Use This Form To Refer Patients Who Are Ready To Quit Tobacco In The Next 30 Days To Quit Now. By following the outlined steps, you can ensure a smooth referral process for patients looking to quit tobacco.

Follow the steps to complete the referral form effectively.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Fill in the 'Provider(s)' section. Input the provider name, contact name, clinic or department, email address, phone number, city, state, zip code, and fax number as necessary.
3. In the 'Patient' section, mark the appropriate box indicating whether the patient is ready to quit. Ensure the patient understands that Quit Now Kentucky will inform their provider about their participation.
4. Ask the patient to specify their preferred times for a quitline coach to call. They can choose from morning, afternoon, evening, or weekend options.
5. Indicate if a message can be left for the patient and whether they require assistance due to hearing impairment.
6. Request the patient's preferred language from the options provided.
7. Make sure all required fields are completed and review the information for accuracy.
8. Once completed, fax the form to 1-800-261-6259 or mail it to the designated address provided at the end of the form.
9. Save changes, download a copy, print it for your records, or share it as needed.

Complete the referral form online today to help patients take the first step towards quitting tobacco.