1. Fax to Assist On-line Training for Certification Sponsored by Maryland Department of Health and Mental Hygiene and University of Maryland Baltimore County Module One: Introduction to Fax to Assist

2. The idea behind Fax to Assist: Healthcare Providers’ opinions are highly respected and influential. If a provider recommends quitting and makes a treatment referral, clients are more likely to make a quit attempt and ultimately stop smoking. Fax to Assist gives providers an additional opportunity to easily, quickly, and effectively connect clients with individualized tobacco cessation help.

3. To become a Certified Fax to Assist Provider: Complete all four modules of the Fax to Assist On-line Training for Certification. Pass the on-line Training Quiz to complete account certification. Use your username and password to access Fax to Assist forms on the MDQuit website.

4. Once you are a Certified Fax to Assist Provider: Download the Fax to Assist Referral Form. Type in your Provider Information to personalize the form for your use. Print the Fax to Assist form. If your client consents to being contacted by the Maryland Quitline, have the client fill out his or her contact information and sign the form.

5. Next Steps: Once the client has consented and signed the Fax Referral Form, Fax it to 1-800-483-3114, it’s that easy! The Quitline will then call your client and offer four sessions of counseling. The Maryland Quitline will inform you about the services your client utilized through the Quitline via fax. This information can be placed in the client’s file for future reference.

6. Provider Follow-Up: MDQuit.org provides a template for a letter that can be personalized and sent to the client a few weeks after the Fax to Assist referral was made. Providers are encouraged to arrange follow-up appointments to discuss the client’s progress towards cessation.

7. This is what the Fax Referral Form will look like. You can download this form, enter the information for your organization, hospital, group, or clinic electronically, and then save it so that you only have to complete this section one time. Next, the client can fill in the second portion and sign, giving permission for the Quitline to call. The form is now ready to be faxed to the Quitline. Confidentiality is assured!

8. Important Things to Know: The Fax to Assist referral may ONLY be used if the client gives their written consent. In order to use Fax to Assist, your practice must be a HIPAA Covered Entity (e.g., doctor’s office, dentist’s office, hospital, clinic or agency site).

9. Summary to become registered Complete All 4 Modules & pass the 20 item quiz Access downloadable Fax Referral form using your username and password Enter your provider information to personalize Fax Referral Form Have client sign form to be contacted by 1-800-QUITNOW Fax to 1-800-483-3114 It’s that EASY!

10. You have finished Module 1. Please proceed to Module 2, which covers The 5 A’s, a brief smoking cessation intervention.Module 2