Cessation Registry Application

Contact Person:

*

Title:

*

Phone:

*

Fax:

E-mail Address:

*

Name of Health Care Delivery System/Clinic/Individual Practice:

*

Street Address:

*

City:

*

State:

*

Zip Code:

*

Phone:

*

Fax:

Counselor(s):

Name:

*

Professional Discipline:

*

PROMISe #:

Attach Certificate:

Location(s):*

Name of Health Care Delivery System:

*

Street Address:

*

City:

*

Zip Code:

*

Phone:

*

County:

*

PROMISe #:

NPI #:

Additional Information:

Counseling Services Provided (check all that apply):

* GroupIndividualPhoneVirtual

Client Type(s): *

Adult
Young Adult (18-24)
Youth (14-17)
Pregnant Woman
LGBT
Practice Patients
Other

Practice Available Language/Verbal Skills:

* EnglishSpanishOther

If your program is approved, would you like information on your program referred to the Department of Human Services for review and approval by Medical Assistance for reimbursement of tobacco cessation services?

* YesNo

* 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

Printed Name of Representative:

*

Title:

*

Date:

*

*Fields Required