TREES
Tobacco Reduction, Education & Enforcement System
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Contact Person Information
Contact Person:
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Title:
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Phone:
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Fax:
E-mail Address:
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System/Clinic/Practice Information
Name of Health Care Delivery System/Clinic/Individual Practice:
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Street Address:
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City:
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State:
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Zip Code:
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Phone:
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Fax:
Cessation Counselor(s)
Counselor(s):
Name:
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Professional Discipline:
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PROMISe #:
Attach Certificate:
Location(s) of Cessation Services
Location(s):
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Name of Health Care Delivery System:
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Street Address:
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City:
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Zip Code:
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Phone:
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County:
Adams
Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Cameron
Carbon
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Franklin
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Indiana
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Lycoming
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Montour
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Out of State
Perry
Philadelphia
Pike
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Schuylkill
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Unknown
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming
York
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PROMISe #:
NPI #:
Additional Information:
Service Information
Counseling Services Provided (check all that apply):
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Group
Individual
Phone
Virtual
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Client Type(s):
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Adult
Young Adult (18-24)
Youth (14-17)
Pregnant Woman
LGBT
Practice Patients
Other
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Practice Available Language/Verbal Skills:
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English
Spanish
Other
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Medical Assistance Information
If your program is approved, would you like information on your program referred to the Department of Public Welfare for DPW review and approval by Medical Assistance for reimbursement of tobacco cessation services?
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Yes
No
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Please select at least one Checkbox to proceed.
Attestation
*
I agree with
Treating Tobacco Use and Dependence, Clinical Practice Guideline: 2008 Update,
for Cessatoin Program Standards & Regulations:
http://www.ahrq.gov/path/tobacco.htm#Clinic
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Printed Name of Organization Representative:
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Title:
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Date:
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