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.
|Get Started Now|
|How do I use the Proactive Fax Referral System?|
|What will the Utah Tobacco Quit Line do?|
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)
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
|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:
|The name of your clinic|
|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.
|The fax number of your clinic|
|The phone number of your clinic. The clinic phone number you provide on the form should be the contact person’s phone number.|
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.||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.|
|What does the Utah Tobacco Quit Line do to comply with HIPAA?|
|Special Instructions for Local Health Departments|
Healthcare Provider Sections
- TRUTH Network Guide
- Ways to Help Patients Quit
- Healthcare Resources
- Tobacco Cessation Coverage
- Continuing Education
- Additional Links