Stop Smoking Program Physician Referral Form
Please print and fill out this form. Fax it to HMSA 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 (808) 952-4452 on Oahu or 1 (800) 210-7210 on the Neighbor Islands.
A stop smoking case manager will contact the patient to begin the process.