Form Instructions
Ready, Set, Quit! Smoking Cessation Program Physician Referral Form
Physicians:
Please print and fill out this form. Fax it to Behavioral Care Connection at the number below.
- Do the 30-second assessment.
- If the patient agrees, have them fill out section #2.
- Fill out the referring physician section.
- Fax the form to the Behavioral Care Connection at (808) 952-4452 on Oahu or 1 (800) 210-7210 from the Neighbor Islands.
A Ready, Set, Quit! case manager will contact the patient to begin the process.