Fax referral system for Quitline – 10/3/05

Q:

We are planning to implement a fax referral system for health care providers to refer patients directly to our Quitline. Would anyone be willing to share the fax referral forms used in their states, or any lessons learned from implementing this kind of program?

A:

1. Alabama: We would be happy to share the fax referral form we are using. We adapted it from the Mississippi Quitline. Please contact Brooke Thorington, Quitline Coordinator, at (334)206-3830. Please note that we have not launched the fax referral system here in Alabama yet, so we haven't tested these forms.
   
   
2. Arizona: see PowerPoint Slides and Fax Referral Form
   
   
3. Colorado: see Fax Referral Form
   
   
4. Florida: see Fax Referral Form
   
   
5. Illinois: see Fax Referral Form
   
   
6. Iowa: see Fax Referral Form
   
   
7. Michigan: Fax referral processes are advantageous because they provide access to a population that may not be informed of cessation services, which can improve reach without increasing inbound call volumes. The important thing to focus on is education of the group or person that is completing the referral forms. They need to tell the patient they are sending the form so the individual is not surprised by the follow-up call that occurs post receipt of the referral form. Many referral forms now include the signature of the tobacco user to encourage the provider to discuss this with the patient prior to signing the form. We also learned that it was important to set a protocol for the number of attempts that would be made to contact people identified by the referral forms since connecting with these tobacco users is sometimes challenging.
   
   
8. New Hampshire: see Fax Referral Form
   
   
9. Rhode Island: Please contact Janet Van Ness with JSI Research and Training Institute. They are handling the implementation of our QuitWorks program. janet_vanness@jsi.com TEL:617-482-9485 FAX:617-482-0617
   
   
10. Texas: see Fax Referral Form
    
    
11. Vermont: Below are two examples of our Vermont fax referral form (the PDFs), and the latest ACS template (Word document). The PDF that says "Jun04" in the document name is the Vermont one we've been using in the field for some time. The second PDF is a revised version in DRAFT form (the document title has 10_4_05 in the title) that reflects an attempt to 1) incorporate the ACS template, 2) allow the fax referral form to be used (alternatively) as a fax referral form to local hospital based cessation services (aka "Ready, Set...STOP program in VT), and 3) include a permission statement that would allow reporting back to health care providers on patient status.
    
    Lastly, the third document (Word document) is the latest ACS generic fax referral form which they want all states working with them to incorporate, with some opportunities to customize with state-specific text/visuals.
    

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