TobaccoFreeUtah.org
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Utah Tobacco Line Fax Referral System

About the Fax Referral System

In the past, the only way a healthcare provider could refer clients to the Utah Tobacco Quit Line was to give them the Quit Line’s toll free phone number. However, some people are uncomfortable initiating contact with the Quit Line and  others simply lose the phone number before they have an opportunity to call. Now, clinicians can directly refer clients using the Utah Tobacco Quit Line Fax Referral  System. The Utah Tobacco Quit Line proactively calls your clients to help them quit.

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Get Started Now
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How do I use the Proactive Fax Referral System?
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What will the Utah Tobacco Quit Line do?


Get Started Now


Enter your clinic information below, then click on the button "Info Entered - 
Go to FAX Page" to get your personalized copy of the fax form. ALL five 
boxes must be filled in. Before printing the form, adjust printer margins to the lowest possible setting. (File/Page Setup/Margins)

Clinic / Hosp /Dept:
Contact Name:
E-mail:
Address:
City:
State:
Zip:
Clinic Fax:
Clinic Phone:

If you have trouble downloading the Fax Referral Form or would like a more perfect copy, send an email to The TRUTH@utah.gov to request a form. In the email message, be sure to include your clinic name, clinic contact person name, clinic fax number, and clinic phone number, and county. Please note that the appearance of the form varies when it is printed from different computers, browsers and printers. It is okay if the form prints imperfectly (for example, if a few of the fields at the bottom are cut off). Imperfect forms will still be accepted by the Quit Line as long as the clinic contact information and mandatory signature are present

How do I use the Proactive Fax Referral System?

Follow these 5 simple steps:
1. Enter your clinic information and download the fax form from this website.  
The information you enter will be automatically printed onto the fax referral 
form to create a form personalized for your clinic. You will need to enter five  fields:
 
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The name of your clinic
 
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The name of a person at your clinic who will act as the clinic contact person
The Utah Tobacco Quit Line will call the contact person for clarification if it  receives an incomplete or illegible form. This person should be someone who  is available to respond to phone calls, such as a secretary or receptionist, rather  than someone who will usually be caring for patients and unable to come to the  phone.
 
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The fax number of your clinic
 
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The phone number of your clinic. The clinic phone number you provide on the  form should be the contact person’s phone number.
 
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The county that your clinic is in

2. Print the form and photocopy it. Before printing the form adjust printer margins to the lowest possible setting. Make enough copies for each of your tobacco-using clients to have their own form.  The appearance of the form varies when printed from different computers, browsers and printers. It is okay if the form prints imperfectly (for example, if a few of the fields at the bottom are cut off). Imperfect forms will still be accepted by the Quit Line as long as the clinic contact information and mandatory signature are present. If you would like a more perfect version, you may also send an email to TheTRUTH@utah.gov with your clinic name, clinic contact person name, clinic fax number, clinic phone number, and county and a personalized form will be emailed to your clinic.

 

3. Ask your tobacco-using clients if they would like the Utah Tobacco Quit Line to  help them quit. If a client would like help, write your name on the form and  ask the client to fill out the rest of the form. The client must sign the form or, if the client is a minor, the client’s guardian must sign the form.



If the client does not want to fill out the form, give the patient the Quit Line’s toll  free telephone number 1.800.QUIT.NOW (1.800.784.8669) or offer a Utah Tobacco Quit Line  card so that the client can contact the Quit Line when they are ready. Do not  pressure clients to fill out the form if they do not want to.

 

4. When the client finishes filling out the form, verify that all items
are filled in, that the handwriting is readable and that the mandatory 
signature is present.

 

5. Fax the form to the Utah Tobacco Quit Line’s toll-free fax number: 
1-800-483-3076.

 

What will the Utah Tobacco Quit Line do?

1. The Utah Tobacco Quit Line calls the client to help them quit using tobacco.  
The Quit Line will begin making attempts to reach the client starting within one  business day of the referral. The first time the Quit Line receives a fax referral form  from a new clinic, the Quit Line may take longer to call the patient because the Quit  Line will need to add the clinic to its database.

The support and counseling services your clients receive depend on their preferences  and their eligibility. To learn more about eligibility, please see State-sponsored Cessation Benefits and Programs.


2, The Utah Tobacco Quit Line faxes your clinic so that you know if your patient  received services. This information is useful for the patient’s health record and to facilitate  follow-up with the patient.
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What does the Utah Tobacco Quit Line do to comply with HIPAA?
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Special Instructions for Local Health Departments

 

 

way to quit


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