| 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? |
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| 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) |
| |
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
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| 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
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| 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.
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| 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 (1-888-567 -TRUTH) 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.
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| 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.
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| 5. |
Fax
the form to the Utah Tobacco Quit Line’s toll-free
fax number:
1-800-483-3076.
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| 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
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