Provider Web Referral

Patient Information

Patient’s first name

Patient’s last name

Patient’s DOB

Primary phone type

Patient’s primary phone

Secondary phone type

Patient's secondary phone

Best contact days

Best contact times

Patient's address

Patient's address 2

Patient's city

Patient's state

Patient's zip

Patient's preferred language

Is it ok to leave a voicemail?

Is patient hearing impaired?

Patient's insurance provider

Insurance Member ID

Clinic Information

Referred by a HIPAA Covered Entity?

Provider First Name

Provider Last Name

Contact First Name

Contact Last Name

Clinic/organization name

Clinic address

Clinic address 2

Clinic city

Clinic state

Clinic zip code

Clinic fax number

Authorization

I am authorized to receive personal health information for the individual being referred. By submitting this form, I verify that the patient being referred has consented to participate in this tobacco cessation program.

Provider Web Referral

Thank you!

Patient Information

Clinic Information

Authorization