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Local Health Department Special Instructions for the Proactive Fax Referral System

Special Instructions

Sharing the Form With Clinicians

Before providing the form to clinicians, obtain their clinic name, fax number and phone number, as well as the name of the person at the clinic who will act as a contact person for the Quit Line if ever necessary.
Type in the clinic name, fax number, phone number and contact person into the appropriate spaces BEFORE giving the form to the clinic. This prevents problems related to incomplete or illegible forms. Provide the clinician with both the English and Spanish forms, so that clinicians can serve both their English-speaking and Spanish-speaking clients.
Provide clinicians with the instructions for using the Utah Tobacco Quit Line Proactive Fax Referral System when you give them the form. The instructions are on The Utah Tobacco Quit Line Proactive Fax Referral System page.
After initial receipt of the personalized form, it is the health care provider’s responsibility to make copies for future use.

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Referring Your Clients to the Quit Line

Local Health Departments may also use the proactive fax referral system to refer LHD clients to the Utah Tobacco Quit Line. To adapt the form for this purpose, you will need to type in the name of the local health department, followed by the program within the local health department, in the space labeled "clinic name". For example, "Clinic Name: Davis County Health Department, WIC" or "Clinic Name: Tri-County Health Department, Health Promotion".

  The Utah Tobacco Quit Line Proactive Fax Referral System

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