Form Instructions

Stop Smoking Program Physician Referral Form

Physicians:
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.