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Get Nebraska Tobacco Quitline Medicaid Form

NEBRASKA TOBACCO QUITLINE-MEDICAID FAX REFERRAL FORM FAX 800 483-3114 Fax must be filled out IN FULL by prescriber or pharmacist PLEASE PRINT CLEARLY. Check if Spanish speaking 6. Patient Medicaid ID 11 digits 7. Provider Name 8. Provider Address Street/City/State/Zip 9. Provider E-mail 10. Provider Phone - 11. Check Fax Sender Pharmacist Prescriber 12. FAX Number of Sender - PLEASE GIVE A COPY TO THE PATIENT BEFORE FAXING TO THE NEBRASKA TO.

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