Patient Information

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Clinic Information

Authorization

  As a HIPAA covered entity, I am authorized to receive personal health information for the individual being referred.

  By submitting this form, I verify that the patient being referred has consented to participate in the tobacco cessation program.

  As a Not Covered Entity, personal health information will not be shared back for the individual being referred.

  By submitting this form, I verify that the patient being referred has consented to participate in the tobacco cessation program.