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Asthma MTM Pilot Checklist Patient Identifier: ___________________________________

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This Checklist is intended to guide you as you conduct the MTM process for the indicated patient. It is suggested that you keep this packet on file for the patient throughout the entire pilot program.

Enrollment Meeting/Phone Call (5 min) Date:________________ Completed by:___________________

Description of study and participation agreement Schedule Initial Visit (must be a LIVE meeting)

o Inform patient to bring in ALL medications, both non-prescription and prescription. o Advise patient to arrive 15 minutes early to fill out paperwork

Notify Kim Roberson of the scheduled Initial Visit

Initial Visit Comprehensive Medication Review (CMR) Date:____________

Completed by:___________________,RPh Enrollment – may be performed by technician (15 minutes)

Enrollment application form and consent forms Health Attitudes Typing Tool and summary guide (adherence survey) (optional)

• http://www.texaspharmacy.org/?page=MTM_Pilot_RXResource > General Patient Assessment Tools

MTR Patient Health and Lifestyle Questionnaire (highlight questions that are critical to complete)

Asthma Control Test™ • Score: ________

Pharmacist meeting with patient (20 minutes) Assess patient adherence. Have they missed any doses?

o If so, educate the patient on the importance of adherence and follow up in about 2 weeks to determine if compliance has improved. After follow-up, document the Encounter claim in the Outcomes system.

Talk with patient about medical, family, social history, problems with medications, health status Complete the CMR and Personal Medication Record and provide a copy to the patient Counsel patient on smoking cessation and refer if necessary using the Quitline Fax Referral

Form Counsel patient on allergen testing if necessary using the Allergy Testing Referral Form Provide patient with an Asthma Care Kit and instruct them to record their peak flow meter

readings daily until the next appointment o Provide patient with the Peak Flow Meter Patient Log

http://www.texaspharmacy.org/?page=MTM_Pilot_RXResource


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After patient leaves Screen for adverse drug reactions, drug interactions, clinical appropriateness, and cost

effectiveness of therapy Develop Medication Action Plan and obtain physician approval for any recommended changes.

o Fax the Asthma Action Plan and Prescription Approval Letter to the physician Fax Quitline Fax Referral Form to 1-800-483-3114 if applicable

o Note: Use your pharmacy’s name under the “Clinic Name” field. Fax Allergen Testing Referral Form to physician if applicable Document CMR and bill through OutcomesMTM™

o If additional MTM services were provided (drug therapy problems were found), document these as a “CMR with Encounter”. Additional claims may be created and saved at this time in the OutcomesMTM™ system until you have determined the result(s).

o If the visit is a CMR with follow-up Encounter where additional patient training is needed, discuss needed follow-up visit where peak flow meter and holding chamber training will be provided. Recommend this be scheduled AFTER physician approves recommended Asthma Action Plan.

Schedule Second Live Visit after receiving physician approval of the Asthma Action Plan and any changes to drug therapy

Second Live Visit (20 – 25 min) Date:________________

Completed by:___________________,RPh Prior to meeting – may be completed by technician

Complete Asthma Control Test™ – Score:______ Pharmacist meeting with patient

Assess if patient has experienced adverse events since initial visit o If so, work with patient and/or physician to resolve the new issue. Upon response from

the patient / physician, document the Encounter claim in the Outcomes system. Assess patient adherence. Have they missed any doses?

o If so, educate the patient on the importance of adherence and follow up in about 2 weeks to determine if compliance has improved. After follow-up, document the Encounter claim in the Outcomes system.

Provide Peak Flow Meter and Holding Chamber training if necessary Discuss Asthma Action Plan approved by the physician. Counsel patient on any drug therapy changes made regarding drug therapy problems found as a

result of the CMR. (new prescriptions, etc) Counsel on health and lifestyle changes. Schedule Telephone Follow-Up (two weeks if DTP identified; four weeks if not)


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Post-Meeting Document information in Medication Action Plan and/or progress notes. If any, fax recommendations for medication changes to physician

Recurring Telephone Follow Up Date:________________ Completed by:___________________,RPh

If a Drug Therapy Problem is identified at any follow-up, the next follow-up should occur at two weeks. Otherwise, all follow-ups are at four-week intervals until the 6-month observation period has ended.

Document information in Medication Action Plan and/or progress notes.

Assess if patient has experienced adverse events since last visit o If so, work with patient and/or physician to resolve issue. Upon response from

patient/physician, document MTM claim in Outcomes system Assess patient adherence. Have they missed any doses?

o If so, educate the patient on the importance of adherence and follow up in about 2 weeks to determine if compliance has improved. After follow up- document MTM claim in Outcomes system.

If any, fax recommendations for medication changes to physician o Notify patient to pick up new prescriptions if necessary

Complete Asthma Control Test ™ Obtain any hospitalization or Emergency Room visit information since last contact Record ACT™ score and hospitalization / ER visit information in OutcomesMTM™ and in the

form below (for each follow-up)

Follow-up Log:

Date

ACT™ Score

Hospitalization since last visit? (Y/N)


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Final Visit (preferred Live) Date:________________ Completed by:___________________,RPh

Document information in Medication Action Plan and/or progress notes.

Complete Asthma Control Test ™ o Score: ______

Obtain any hospitalization or Emergency Room visit information since last contact Record ACT™ score and hospitalization / ER visit information in OutcomesMTM Have patient complete the Patient Satisfaction Survey

No further meetings required

Pre-‐Visit

1. Identify patients with Asthma/COPD taking 4 or more chronic medications who are receiving pharmacy services at the study location sites. 2. Contact patients who have expressed interest in participating in the pilot program.

Telephone Contact 1. Provide description of study 2. Schedule first visit 3. Remind patient to avoid food, smoking & caffeine at least 30 minutes prior to

appointment 4. Remind patient to arrive 15 minutes early to complete enrollment forms

Live Contact 1. Provide description of study 2. Complete enrollment forms if time permits, otherwise, remind patient to arrive

15 minutes early to Initial Visit 3. Schedule first visit 4. Remind patient to avoid food, smoking & caffeine at least 30 minutes prior to

appointment

After Initial Visit: 1. Screen for adverse drug reactions, drug interactions, clinical appropriateness, cost effectiveness, and other drug therapy problems 2. Fax Asthma Action Plan, Prescription Approval Letter, Allergen Testing Referral Form, and other recommendations to the physician 3. Send Quitline FAX Referral Form to 1-‐800-‐483-‐3114 if applicable. 4. Document CMR and bill through OutcomesMTM™ After Physician Approval/Denial is received, schedule the Second Live Visit.

During Initial Visit: 1. Assess patient adherence 2. Discuss patient’s medical history, social history, family history, health status, etc. 3. Complete CMR. 4. Fill out Personal Medication Record and provide a copy to the patient. 5. Counsel patient on smoking cessation and refer using the Quitline FAX Referral Form

if necessary 6. Counsel patient on allergen testing and refer to physician using the Allergen Testing

Referral Form if necessary 7. Provide patient with an Asthma Care Kit and instruct them on the proper use of a

Peak Flow Meter – ask patient to record their twice-‐daily readings on the Peak Flow Meter Patient Log

When patient arrives prior to Initial Visit: Pharmacist Tasks: 1. Obtain a complete list of medications (Prescription and Over-‐the-‐Counter), any

available clinical data 2. Obtain a brief patient history using appropriate forms from the MTM Guide Packet Technician Tasks: 1. Confirm patient meets pilot criteria and has completed all forms in the Patient

Enrollment Packet 2. Health Attitudes Typing Tool (optional) 3. MTR Patient Health and Lifestyle Questionnaire 4. Asthma Control Test™

Initial Visit – Comprehensive Medication Review (CMR)

Second Live Visit (Approx. 2 weeks later)

Prior to meeting with patient: 1. Complete Asthma Control Test™

During Second Live Visit: 1. Assess if patient has experienced adverse events since initial visit. 2. Assess patient adherence. 3. Provide Peak Flow Meter and Holding Chamber training if necessary. 4. Discuss Asthma Action Plan that was approved by physician – fill in any missing information 5. Counsel patients on any changes to drug therapy as a result of the CMR. 6. Counsel on health and lifestyle changes if necessary

After Second Live Visit: 1. Document the encounter in OutcomesMTM™ 2. Document information in progress notes if necessary. 3. If any, fax recommendations for medication changes to the physician.

Were any drug therapy problems found?

Final Live Visit (6 months after enrollment) 1. Complete ACT™ and obtain hospitalization information 2. Document in OutcomesMTM™ 3. Have patient complete the Patient Satisfaction Survey

4-‐Week Telephone Follow-‐Up 1. Reiterate key discussion topics (adherence, adverse events,

etc.) 2. Complete Asthma Control Test™ and document information 3. Continue to document in OutcomesMTM™ 4. Identify any drug therapy problems

Yes 2-‐Week Telephone Follow-‐Up 1. Contact the patient to notify them of any changes to therapy 2. Encourage them to pick up new prescriptions 3. Reiterate key discussion topics (adherence, adverse events, etc.) 4. Complete Asthma Control Test™ and document information 5. Continue to document in OutcomesMTM™ 6. Identify any drug therapy problems.

No

Patient Health and Lifestyle Questionnaire This questionnaire is based on the information available to the pharmacist as provided by the patient. This questionnaire is to remain in the patient’s chart in the pharmacy and

can be used as a reference when communicating with other healthcare providers.

Patient Identifier: Date of Birth: Race: Gender : M / F

Pharmacist/Student Intern: Date Prepared: Patient Height:

Primary Pharmacy and Phone Number:

Patient Weight:

Waist Circumference:

Type of MTM visit: Initial Visit Follow-‐up Visit Blood Glucose: HgA1c:

Lipids: Total Cholesterol: LDL: HDL: Triglycerides:

What questions does the patient have about his/her medications or disease states?

Medication Allergies and Adverse Drug Reactions (if known):

Today’s Blood Pressure (in the pharmacy): Does the patient take at-‐home blood pressure readings? Y / N

If so, list at home blood pressure readings here:

Does the patient drink alcoholic beverages? Y / N If so, what type and how often?

Does the patient drink caffeinated beverages? Y / N If so, what type and how often?

Does the patient smoke or use tobacco products? Y / N If so, what type?

For how long? How much per day?

Does the patient salt their food? Y / N Does the patient want to lose weight? Y / N

Does the patient exercise? Y / N If so, how often and how . does the patient exercise?

Medical Conditions (Check all that apply):

Alcoholism Breastfeeding Depression Heart failure Obesity

Chest pain Cancer Diabetes High cholesterol Osteoporosis

Arthritis Headache GI disorder High blood pressure Pregnancy

Asthma Pain Glaucoma Kidney disease Seizure disorder

Bleeding disorder COPD Heart disease Liver disease Thyroid disease

Other:

Additional Patient Information: Is the home heated/cooled by central heat and air? Y / N Are any rooms in the house heated by a kerosene heater or fireplace? Y / N

Is a swamp cooler used to cool any room in the house? Y / N Is the house carpeted? Y / N

Is the patient’s room carpeted? Y / N Are there any stuffed animals in the patient’s room? Y / N

Does the home have a basement? Y / N

Is the patient’s room located in the basement? Y / N

Are there pets in the home? Y / N

If so, what type and how many?

How many people live in the home?

Do any of them smoke? Y / N

Does the home have a problem with leaks in the ceiling, windows, or plumbing that

may lead to mold? Y / N

Are the patient’s mattress and pillow encased in anti-‐allergenic dust covers? Y / N Does the home have a problem with cockroaches? Y / N

Do any of the patient’s siblings or birth parents suffer from Asthma? Y / N If so, who?

Are any rooms in the house or attached to the house used to store/use varnishes, thinner, patients, petroleum products, or other chemicals? Y / N

Dose the patient routinely use any of the following medications? (Select all that apply)

Visine (or other OTC eye drops) ❑ Acetaminophen (Tylenol) ❑ Aspirin ❑ Cold medications that contain acetaminophen ❑

Does the patient routinely consume any of the following foods? (Select all that apply)

Beer ❑ Wine ❑ Grape Juice ❑ Wine vinegar ❑

Pickles ❑ Sauerkraut ❑ Lemon Juice ❑ Lime Juice ❑

Shrimp ❑ Molasses ❑ Dried fruit other than raisins or prunes ❑ Processed potatoes (French fries, tator tots, etc.) ❑

Relevant Family History (1st degree relatives, Marital Status, Children, etc.):

Relevant Social History (use of illicit drugs):

Immunizations: Meningococcal Y / N Date: _____ / _____

Influenza Y / N Date: _____ / _____

Pneumococcal Y / N Date: _____ / _____

Tdap Y / N Date: _____ / _____

Zostavax/Shingles Y / N Date: _____ / _____

Hepatitis A Y / N Date: _____ / _____

Hepatitis B Y / N Date: _____ / _____

AsthmA Control test ™

the AsthmA Control test™ is a quick test for people with asthma 12 years and older. It provides a numerical score to help assess asthma control.

INSTRUCTIONS: 1. Write the number of each answer in the score box provided. 2. Add up the score boxes to get the TOTAL. 3. Discuss your results with your doctor.

Name: Today’s Date:

If your score is 19 or less, your asthma may not be as well controlled as it could be.No matter what your score is, share the results with your healthcare provider.

© 2012 The GlaxoSmithKline Group of Companies All rights reserved. Produced in USA. AD5863R0 June 2012

More than once a day [1]

Once a day [2]

3 to 6 times a week [3]

Once or twice a week [4]

Not at all [5]

2. During the past 4 weeks, how often have you had shortness of breath?

4 or more nights a week [1]

2 or 3 nights a week [2]

Once a week [3]

Once or twice [4]

Not at all [5]

3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

3 or more times per day [1]

1 or 2 times per day [2]

2 or 3 times per week [3]

Once a week or less [4]

Not at all [5]

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?

Not controlled at all [1]

Poorly controlled [2]

Somewhat controlled [3]

Well controlled [4]

Completely controlled [5]

5. How would you rate your asthma control during the past 4 weeks?

1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?

All of the time [1]

Most of the time [2]

Some of the time [3]

A little of the time [4]

None of the time [5]

SCORE

TOTAL:

Copyright 2002, by QualityMetric Incorporated.ASTHMA CONTROL TeST is a trademark of QualityMetric Incorporated.

This material was developed by GlaxoSmithKline.

Peak Flow Meter Patient Log Please bring this form with you to your follow-up appointment at the pharmacy.

Name: ________________________________________

DOB: _____/_____/____________

Date

Peak Flow Meter Reading

Date


Date


Date


Date


Date


This sample Medication-Related Action Plan (MAP) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient (or other user) should not, under any circumstances, solely rely on, or act on the basis of, the MAP or the information therein. If he or she does so, then he or she does so at his or her own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the MAP is not a substitute for obtaining professional healthcare advice or treatment. This MAP may not be appropriate for all patients (or other users). TPA assumes no responsibility for the accuracy, currentness, or completeness of any information provided or recorded herein.

Personal Medication Record

Patient Name: Date of Birth:

Pharmacist/Intern/Technician: Date Prepared:

Pharmacy: Pharmacy Phone:

Emergency Contact Name/Number: Physician Contact Name/Number:

Prescription Medications:

Medication Name Dose Route Frequency Indication Duration of Therapy Physician/Comments

Over-the-Counter Medications:

Herbal Supplements:

Dietary Supplements:

MEDICATION ALLERGIES AND REACTIONS:

This sample Medication-Related Action Plan (MAP) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient (or other user) should not, under any circumstances, solely rely on, or act on the basis of, the MAP or the information therein. If he or she does so, then he or she does so at his or her own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the MAP is not a substitute for obtaining professional healthcare advice or treatment. This MAP may not be appropriate for all patients (or other users). TPA assumes no responsibility for the accuracy, currentness, or completeness of any information provided or recorded herein.

Doing Well■ No cough, wheeze, chest tightness, or

shortness of breath during the day or night■ Can do usual activities

And, if a peak flow meter is used,

Peak flow: more than(80 percent or more of my best peak flow)

My best peak flow is:

Before exercise

Take these long-term control medicines each day (include an anti-inflammatory).

Medicine How much to take When to take it

❐ 2 or ❐ 4 puffs, every 20 minutes for up to 1 hour❐ Nebulizer, once

Medical Alert!■ Very short of breath, or■ Quick-relief medicines have not helped, or■ Cannot do usual activities, or■ Symptoms are same or get worse after

24 hours in Yellow Zone

-Or-

Peak flow: less than (50 percent of my best peak flow)

Take this medicine:

❐ ❐ 4 or ❐ 6 puffs or ❐ Nebulizer(short-acting beta2-agonist)

❐ mg (oral steroid)

Then call your doctor NOW. Go to the hospital or call an ambulance if:■ You are still in the red zone after 15 minutes AND ■ You have not reached your doctor.

For: Doctor: Date:

Doctor’s Phone Number Hospital/Emergency Department Phone Number

Add: quick-relief medicine—and keep taking your GREEN ZONE medicine.

If your symptoms (and peak flow, if used) return to GREEN ZONE after 1 hour of above treatment: ❐ Continue monitoring to be sure you stay in the green zone.

-Or-If your symptoms (and peak flow, if used) do not return to GREEN ZONE after 1 hour of above treatment:

❐ Take: ❐ 2 or ❐ 4 puffs or ❐ Nebulizer(short-acting beta2-agonist)

❐ Add: mg per day For (3–10) days(oral steroid)

❐ Call the doctor ❐ before/ ❐ within hours after taking the oral steroid.

Asthma Is Getting Worse■ Cough, wheeze, chest tightness, or

shortness of breath, or■ Waking at night due to asthma, or■ Can do some, but not all, usual activities

-Or-

Peak flow: to (50 to 79 percent of my best peak flow)

(short-acting beta2-agonist)

GR

EE

NZ

ON

ER

ED

ZO

NE

YE

LLOW

ZO

NE

See the reverse side for things you can do to avoid your asthma triggers.

First

Second

❐ ❐ 2 or ❐ 4 puffs 5 minutes before exercise

■ Trouble walking and talking due to shortness of breath ■ Take ❐ 4 or ❐ 6 puffs of your quick-relief medicine AND

■ Lips or fingernails are blue ■ Go to the hospital or call for an ambulance NOW! (phone)

DANGER SIGNS

Asthma Action Plan Prescriber Authorization:__________________________________________

Prescription Approval Letter

Dr. _____________________________________, Date: ______________ I am pleased to inform you that our mutual patient, ___________________________________, has chosen to participate in the Texas Pharmacy Association Medication Therapy Management Pilot Project. This program provides self‐care education, frequent monitoring, and structured patient accountability in a multi‐collaborative setting consisting of the patient, pharmacist, and practitioner, with the goal of coordinating guideline‐based1 asthma care to improve patient outcomes. As part of the project, a Comprehensive Medication Review (CMR) and Medication Therapy Management (MTM) Session was recently performed here at _______________________________ . The purpose of this MTM Session was to help our mutual patient manage complex drug therapies used for asthma. During this session, several items were addressed regarding our patient’s asthma, including the frequency, severity, and nature of our patient’s symptoms, the amount of exacerbations within the past year, and the amount of asthma‐related hospitalizations within the past year. We also discussed the development of an Asthma Action Plan based on symptoms and peak flow meter results, and education was provided regarding when and how to implement the Asthma Action Plan. Based on this information, I would like to recommend for your approval the following drug therapies for our patient’s Asthma Action Plan. Our patient understands that these drug therapies at these doses are to be used solely for acute asthma exacerbations and are based on severity of symptoms and peak flow meter results (see below). Furthermore, our patient has been educated on identifying and recognizing the current status of their asthma during an acute exacerbation, as well as what steps should be taken. GREEN ZONE: No symptoms of exacerbation; Peak flow ≥ 80% of personal best

Continue long‐term control medicines each day

YELLOW ZONE: Moderate symptoms of exacerbation; Peak flow 50 – 79% of personal best Albuterol for quick relief; Prednisone regimen if necessary

RED ZONE: Severe symptoms of exacerbation; Peak flow < 50% of personal best Quick‐relief Albuterol AND Prednisone regimen; Seek medical attention On page 2 of this fax, you will find our patient’s information, as well as a few drug therapy options and dosages for your selection. Please select ONE Albuterol dosing regimen and ONE Prednisone dosing regimen for our patient, and I will ensure that our patient receives additional counseling regarding the use of these medications for the treatment of an acute asthma exacerbation. Thank you for your support of the Texas Medicaid Medication Therapy Management Pilot Project and our efforts to coordinate guideline‐based1 asthma care. Sincerely, _____________________________________________ , R.Ph. ¹ National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma: Summary Report 2007. Bethesda, MD: National Institutes of Health, US Dept of Health and Human Services, National Heart, Lung, and Blood Institute; 2007.

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Prescription Approval Letter

Page 2 of 2

PATIENT NAME: _____________________________________ DOB: _____________________ ADDRESS: __________________________________________ PHONE: ___________________ NUMBER OF ASTHMA EXACERBATIONS / HOSPITALIZATIONS IN THE PAST YEAR: ____________________ PHARMACY: __________________________________________________________________________ PHARMACY PHONE: ______________________ PHARMACY FAX: _________________________ PRESCRIPTION (PLEASE SELECT ONE):

Albuterol MDI (90 mcg/puff): Inhale 4 – 8 puffs by mouth every 20 minutes up to 4 hours, then

every 1 – 4 hours as needed

Albuterol nebulizer solution 0.083% (2.5 mg/3 mL): Use 1 – 2 vials via nebulizer every 20

minutes for 3 doses, then every 1 – 4 hours as needed

Other:

(Please write here) PRESCRIPTION (PLEASE SELECT ONE):

Prednisone 40 mg by mouth once daily for

5 | 7 | 10 days (please circle one)

Prednisone 30 mg by mouth twice daily for


Prednisone 60 mg by mouth once daily for


Other:

(Please write here) PHYSICIAN NAME: ______________________________________________________________________ ADDRESS: ______________________________________________ PHONE: ___________________ SIGNATURE: ____________________________________________ DATE: ____________________ ***A physician’s signature indicates that this form has been approved as a VALID PRESCRIPTION to be dispensed by the pharmacy

Allergen Testing Referral Form Date: ____/____/_______

Dr. ____________________________, Our records indicate that your patient, _____________________________________, has not been tested for common respiratory inhalant allergens that may be contributing to their asthma symptoms. The NIH Guidelines for the Management of Asthma recommends the assessment of allergic triggers in all patients diagnosed with persistent asthma. Specifically, all patients prescribed a daily medication to control their symptoms should be tested to reliably determine their sensitivity to inhaled allergens. In vitro IgE testing has recently been approved to be paid for by several Texas Managed Medicaid Plans (listed below).

Typically, Asthma Action Plans for adults and children include a checklist of asthma triggers, both allergic and non-allergic. However, without information gained from IgE testing, documentation of a patient's specific allergic triggers is limited to qualitative information provided by the patient. Elevated specific IgE test results, when consistent with patient history, symptoms, and clinical exam, support the diagnosis of allergy and allow for more effective management of the allergy, including pharmacotherapy. If you have not done so, you may order the IgE testing from the lab corresponding to the patient's Texas Managed Medicaid Plan as indicated below. If you have any questions or concerns, please contact me using the contact information provided below. Thank you for your commitment to improve the care of your patient with persistent asthma. Sincerely, _________________________________________ Phone: _______________________________ Fax: ______________________________ Email: _______________________________________

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Texas Managed Medicaid Plans and corresponding lab providers

(Pharmacist: Please indicate the plan in which the patient is enrolled by checking the corresponding box)

Plan Lab Provider Aetna Quest, CPL Aetna Better Health Quest Amerigroup Quest BCBS TX Quest CHRISTUS Health Plan Quest Community First Health Plans Quest Community Health Choice Quest Cook Children’s Health Plan Quest Driscoll Children’s Health Plan Quest El Paso First Premier Quest FirstCare STAR Quest HealthSpring Quest Molina Healthcare Quest Parkland Healthfirst Quest Right Care from Scott and White Health Plan Quest Sendero Quest Seton CPL Superior Health Plan Quest Texas Children’s Health Plan Quest United Healthcare Community LabCorp Other: _______________________________ Information is current as of 1/8/14; please verify coverage before referring patient to lab. This is not an exhaustive list.

Quitline FAX Referral FormFax Number: 1-800-483-3114

PROVIDER INFORMATION: Fax Sent Date: / /

Clinic Name:

Health Care Provider:

Contact Name:

I am a HIPAA-Covered Entity (Please check one) Yes No I Don’t Know

Fax: ( ) – Phone ( ) –

Comments:

PATIENT INFORMATION: Gender: male / female Pregnant? Y N

Patient Name: DOB: / /

Address: City: Zip:

Primary #:( ) – Type: HM WK CELL OTHER

Secondary #:( ) – Type: HM WK CELL OTHER

Language Preference (check one): English Spanish Other –

Tobacco Type (check ALL that apply): Cigarettes Smokeless Tobacco Cigar Pipe

I am ready to quit tobacco and request the Quitline contact me to help me with my quit plan.(Initial)

I DO NOT give my permission to the Quitline to leave a message when contacting me. (Initial)

Patient Signature: Date: / /

The Quitline will call you. Please check the BEST 3-hour time frame for them to reach you. NOTE: The Quitline is open 7 days a week; call attempts over a weekend may be made at times other than during this 3-hour time frame.

6am - 9am 9am - 12pm 12pm - 3pm 3pm - 6pm 6pm - 9pm

Within this 3-hour time frame, please contact me at (check one): Primary Secondary

© 2005 Free & Clear, Inc. All rights reserved.

Confidentiality Notice: This facsimile contains confidential information. If you have received this facsimile in error, please notify the sender immediately by telephone and confidentially dispose of the material. Do not review, disclose, copy, or distribute.

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