Oklahoma helpline fax referral form 2026

1. Click ‘Get Form’ to open the Oklahoma Helpline Fax Referral Form in our editor.
2. Begin by filling out the Provider Information section. Enter the clinic name, zip code, and select the health care provider type (Physician, Nurse, or Clinic Staff). Provide your contact name, fax number, and phone number.
3. Indicate whether you are a HIPAA covered entity by checking 'YES', 'NO', or 'DON’T KNOW'.
4. Next, complete the Patient Information section. Fill in the patient's name, date of birth, gender, address, city, primary phone number (home/work/cell), and zip code. Also provide a secondary phone number if applicable.
5. Select the language preference by checking either English, Spanish, or Other.
6. Initial to confirm readiness to quit tobacco and request contact from the Oklahoma Tobacco Helpline. If you do not want messages left when contacted, initial that option as well.
7. Have the patient sign and date at the bottom of the form.
8. Finally, check your preferred 3-hour time frame for a call from the Helpline and indicate whether they should contact you on your primary or secondary number.

Start using our platform today to easily fill out your forms for free!