New York State Smokers’ Quitline
1 – (866) – NY – QUITS (1-866-697-8487)
Patient stamp, label OR Name, record number, DOB, date:
Fax-to-Quit
Fax Referral Form
Fax form to: 1-866-QUIT-FAX (1-866-784-8329)
TOBACCO TREATMENT CHECKLIST
ADVISE smoker to stop smoking. Recommended stop-smoking advice: “I strongly advise you to quit smoking and can help you.” ASSESS readiness to quit: ASSIST smoker to quit: Nicotine Replacement (CIRCLE): Other (CIRCLE): ARRANGE follow-up: Ready to quit Brief counseling patch bupropion gum (Zyban® Thinking about quitting lozenge inhaler or Wellbutrin SR®) Not ready to quit nasal spray
Prescription medications if appropriate:
Refer to NYS Smokers’ Quitline by faxing this page (toll-free) to 1-866-784-8329
REFERRAL SOURCE
Referred by: Name (Please print) Phone (area code + number) ( ) ________ - _______________
______________________________________________________________
Group/Agency/Hospital/Organization
Fax (area code + number) ( ) ________ - _______________
______________________________________________________________
Street Address/City/State/Zip Code
______________________________________________________________
Send progress report to (If different from above): Name (Please print) ________________________________________________________________________________________________ Group/Agency/Hospital/Organization ________________________________________________________________________________________________ Street Address/City/State/Zip Code ________________________________________________________________________________________________
DO NOT CALL PATIENT UNTIL AFTER (mm/dd/yy): _______ / _________ / _________
Phone (area code + number) ( ) ________ - _______________
Fax (area code + number) ( ) ________ - _______________
PATIENT INFORMATION
Patient’s name (Please print) First: ___________________________ Phone number (including area code): Best time to call: Street Address: ( Last: __________________________________________ ) __________ - _________________ Afternoon (Noon to 5 pm) Date of Birth (mm/dd/yy): ______/________/________ Yes No English
May we leave a message? Language:
Morning (9 am to noon)
Evening (5 pm to 9 pm)
_______________________________________________________________________ Zip Code: _____________________
Spanish Other: _______________ Health Insurance? Yes No
City: _________________________________________________ E-mail: _______________________________
Insurance carrier: ____________________________________________ If Medicaid, ID Number: _______________________________________
@
________________________ . __________
PERMISSION
I (undersigned) give permission for the support staff of the New York State Smokers’ Quitline to contact me, coach me in quitting smoking, and give feedback regarding my progress to the health care provider listed above and permission for that provider to forward the information to other relevant health care providers. ________________________________________________________________________________________________________
Signature of Patient (or Agent if authorization was verbal). Signature is required for patient to be called. ReferFormRV1-05-04.doc
_____/_____/_____
Date