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

Youth Palm Card

Youth Palm Card

LGBTQ  Palm Card

LGBTQ
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

Mental Health Palm Card

Mental Health 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

Mental Health Poster

Mental Health Poster

Business Cards

Quit Now Indiana Business Cards

Quit Now Indiana Business Cards

Equit/Web Coach Business Cards

Equit/Web Coach Business Cards

Quit Now Indiana Business Cards (Spanish)

Quit Now Indiana Business Cards (Spanish)

 

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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Address
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Phone