Forms

As per the application requirements listed in the Expression of Interest for the smoking cessation program, participating pharmacists must: 

• agree to collect smoking cessation data utilizing prescribed program forms and to submit these forms to an evaluation team in a timely manner

• agree to actively participate in all stages of the smoking cessation program, including evaluation

​Participating pharmacists must also be up to date on Manitoba’s Personal Health Information Act (PHIA).

Documentation has been developed for the program and includes the following downloadable forms: 

• Full Claim Submission Process
• SIB Required Forms in Fillable PDF
• SIB Consent Form
• Smoker's Helpline Referral Form *new*
• Health provider client referral form

 

Both pharmacies and pharmacists must agree to participate in a mandatory Orientation Session, complete all mandated forms and documentation in full, and commit time and effort to the Readiness to Quit, Initial Assessment, and Follow Up phases of the program. Follow up with patients requires follow up communication and documentation with each enrolled patient.