provider Materials Order Form

 
 

Palm Cards

 Cessation Palm Card

Cessation Palm Card

 Online Referral Portal Palm Card

Online Referral Portal Palm Card

 Equit/Web Coach Palm Card

Equit/Web Coach Palm Card

 Pregnancy Palm Card

Pregnancy Palm Card

 Diabetes Palm Card

Diabetes Palm Card

 Opioids Palm Card

Opioids Palm Card

 E-Device Palm Card

E-Device
Palm Card

 Spanish Cessation Palm Card

Spanish Cessation Palm Card

 Spanish Pregnancy Palm Card

Spanish Pregnancy Palm Card

 Spanish E-Device Palm Card

Spanish E-Device
Palm Card

 Smoking, Asthma, Kids Palm Card

Smoking, Asthma, Kids Palm Card

 Spanish Equit/Web Coach Palm Card

Spanish Equit/Web Coach Palm Card

 Spanish Opioids Palm Card

Spanish Opioids Palm Card

 Spanish Smoking, Asthma, Kids Palm Card

Spanish Smoking, Asthma, Kids Palm Card

POSTERS

 Cessation Poster

Cessation Poster

 Pregnancy Poster

Pregnancy Poster

 Opioid Poster

Opioid Poster

 Smoking/Asthma Poster

Smoking/Asthma Poster

 Equit Poster

Equit Poster

 Diabetes Poster

Diabetes Poster

 E-Device Poster

E-Device Poster

Business Cards

 Quit Now Indiana Business Cards

Quit Now Indiana Business Cards

 Equit/Web Coach Business Cards

Equit/Web Coach Business Cards

 

Referral Pads

 Referral Pads - 25 Sheet

Referral Pads - 25 Sheet

 
 

Downloadable FORMS

 Tobacco Cessation Guidelines

Tobacco Cessation Guidelines

 Fax Referral Form

Fax Referral Form

 Pharmacotherapy Chart

Pharmacotherapy Chart

 Preferred Provider Enrollment Form

Preferred Provider Enrollment Form

 Medicaid Info

Medicaid Info

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