Referral form - NYSmokeFree 2026

1. Click ‘Get Form’ to open the Referral form - NYSmokeFree in the editor.
2. Begin by filling out the PROVIDER(S) section. Clearly print your Provider Name, Clinic/Hospital/Organization, and complete the Address, City/State/Zip fields.
3. Next, provide your Contact Name, Phone, Fax, and Email. Ensure all information is accurate for effective communication.
4. Check any relevant boxes if the patient has specific conditions such as being pregnant or having an irregular heartbeat. This is crucial for medication authorization.
5. Sign the form to authorize the WV Tobacco Quitline to send nicotine replacement therapy if applicable. If the patient is not present, indicate verbal consent.
6. Move on to the PATIENT section. The patient should print their name, address, and other personal details clearly.
7. Ensure that the patient understands their rights regarding confidentiality and participation by checking the appropriate box.
8. Complete additional fields like Date of Birth, Insurance Carrier, and contact preferences including phone numbers and language preference.
9. Finally, have the patient sign and date the form before submitting it via fax to ensure a smooth referral process.

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