Forms

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

 

‚ÄčParticipating 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: 

 

SIB Required Forms in Fillable PDF

 

SIB Consent Form

 

Full Claim Submission Process

 

Claim Submission Quick Reference Guide

 

 

 

 

Smoker's Helpline Referral Form *new*

 

 

 

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.