IT OPerations manual

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Program Instructions
Revised March 1, 2014
Program Instructions
I.
GENERAL INSTRUCTIONS
IMPORTANT: Every field on this form needs to be filled in entirely. Any omissions will require the
form to be returned to be completed.
For each adult (age 18 and over) enrolled in HUSKY A, C, and D, please complete the Registration Forms, as
follows:
 Part A (Basic information): To be completed by clinical staff within the practice and submitted to HUSKY Health
upon completion.
 Part B (Smoking Habits & Clinical Status): To be completed by clinical staff within the practice and submitted to
HUSKY Health upon completion.
 Part C (Informed Consent): To be completed and signed by the patient with assistance from clinical
staff within the practice (if requested).
 This form is to be retained by the provider and submitted to HUSKY Health upon completion.
II.
FORM INSTRUCTIONS
Electronic Submission of the Enrollment Form:
 Please read the instructions before submitting. It is important to download the file before filling out and to save
the file before submitting the document. Please submit using the current form on the website, as the content is
periodically revised.
 This form was created using Adobe® Acrobat® 9 Pro Version 9.5.0. It has been tested using Adobe® Acrobat®
Reader 9 and X and Microsoft® Internet Explorer® 8.0.
 The form should be submitted using an Adobe Acrobat application using Internet Explorer.
The free version of Acrobat Reader is available from Adobe at http://get.adobe.com/reader/.
 Save this form as a PDF as follows: practicenameR2Q_PatientName_Date.pdf
Save and retain this form for any updates or changes to prevent lost data.
After this form is saved, click the SUBMIT button on the last page to transmit the data to HUSKY Health. You
will automatically receive a Message Received reply with a tracking number. Save the Message Received reply
and note the tracking number for future reference and any future additions or changes to your form.
I.
GENERAL INSTRUCTIONS
2
II.
FORM INSTRUCTIONS
2
III.
REQUIRED INFORMATION
3
IV.
Date of Enrollment
3
1.
Practice Information
3
2.
Provider Information
3
3.
Patient Information
3
4.
Smoking Status
3
5.
Education
4
6.
Smoking Habits
4
7a.
Pregnancy Status
5
7b.
Severe & Persistent Mental Illness (SPMI)
5
PATIENT INFORMED CONSENT
8. Smoking Cessation Information
FORM023B REWARDS TO QUIT Program Referral Form
6
6
Revised 03.01.2014C-E
2
Part A: Basic Information
III.
1.
1.a
1.b
I
REQUIRED
INFORMATION
I of Enrollment (mmddyyyy):
Date
I
I
Practice
Information
I
Practice Name:
I
Practice CMAP Number:
Practice Address Line 1:
Practice Address Line 2:
1.c
Practice City:
Practice State:
Practice Zip Code (nine-digit):
2.
Provider Information
Provider First Name:
MI:
2.a
Provider Last Name:
2.b
3.
Provider CMAP Number:
Patient Information
Patient First Name:
3.a
Patient Last Name:
3.b
Patient 9-Digit HUSKY ID Number:
3.c
Patient Date of Birth
(mmddyyyy):
3.d
Patient Identification:
Gender:
Select one. . .
Race:
Select one. . .
Ethnicity:
Select one. . .
Patient Address Line 1:
Patient Address Line 2:
3.e
Patient City:
Patient State:
Patient Zip Code (five-digit):
3.f
Patient Primary Phone Number:
If cell phone check box
3.g
Patient Email Address:
4.
4.a
Primary
Secondary
Other
Smoking Status
Has patient smoked one or more cigarettes in the last 30 days?
Yes
No
If the answer to 4.a is NO, please click the Submit button on the last page. No further action is necessary.
If answer to 4.a is YES, please complete Parts B and C before clicking Submit button.
FORM023B REWARDS TO QUIT Program Referral Form
Revised 03.01.2014C-E
3
Part B: Smoking Habits and Clinical Status
To be completed by clinical staff within the practice and submitted using the Submit button on the last page.
5.
5.a
6.
Education
Highest level of patient’s education? Select one. . .
Patient’s Smoking Habits
Mark Box for YES
Patient smokes every day.
6.a
How often does patient
smoke cigarettes?
Patient smokes, but not every day.
Patient smokes less than a pack per month.
Enter Number Smoked
# cigarettes a day.
# cigarettes a week.
Patient also smoke cigars.
6.b
Does patient use any
other tobacco products?
(Check all that apply)
Patient also uses “smokeless tobacco” (e.g. snus, orbs, strips, etc.).
No, patient only smokes cigarettes.
6.c
Would patient like to quit
smoking, or smoke less?
6.d
Has patient tried
to quit smoking before?
If YES, when did patient
last try to quit?
Select one. . .
Yes
No
Select one. . .
6.e
If answer to 6.d is NO, please
answer 6.f, 6.g, 6.h and 6.i.
6.f
6.g
6.h
6.i
6.j
Did you not try to quit or smoke
less before because you thought it
would cause too much stress?
Did you not try to quit or smoke
less before because you thought
that if you reduced or quit that you
would gain weight?
Did you not try to quit or smoke
less before because you were
worried about withdrawal
symptoms?
Did you not try to quit or smoke
less before because you were not
sure how to quit?
Has patient ever used a nicotine
replacement therapy (NRT) product
or prescription medication
to help quit smoking?
(e. g., lozenge, gum, patch, inhaler,
nasal spray, Chantix, or Zyban)
FORM023B REWARDS TO QUIT Program Referral Form
Yes
No
Yes
No
Yes
No
Yes
No
Yes, patient is now using a medication or nicotine replacement therapy (NRT).
Yes, patient has used a medication or nicotine replacement therapy (NRT) in the past.
No
Revised 03.01.2014C-E
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Part B: Smoking Habits and Clinical Status
6.k
Have you ever had counseling
before to quit smoking?
Yes
No
6.l
Did you ever use the telephone
Quitline to help you quit smoking?
Yes
No
7.
Patient’s Clinical Status
(EX: March 1, 2013 = 03/01/2013)
mmddyyyy
Patient is pregnant, and is due:
7.a
Pregnancy Status:
Patient gave birth within the last 6 months, born:
Patient is not pregnant.
Not applicable.
7.b
Severe & Persistent Mental Illness
(SPMI)
(Do not ask enrollee, verify from
Medical Record)
FORM023B REWARDS TO QUIT Program Referral Form
Yes
No
Revised 03.01.2014C-E
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Part C: Informed Consent
IV.
I
INFORMED
CONSENT
The RewardsI to Quit program is a study to help us learn how to better help people quit smoking. If you participate in Rewards to Quit, you will be
helping us by giving us important information.
I
If you agree be in the study, here is what you will do:
I some questions about your health and your smoking habits at different times during the program: soon
(1) Answer
after
I you agree to participate (by signing this form), 3-months after you agree, and 12-months after you agree.
(2) Participate in some quit smoking activities, if you choose to.
I
If you agree, you will be in the study for fourteen (14) months.
Risks and Benefits: This study will benefit you by helping you quit smoking, if you choose to do the quit-smoking activities. Quitting smoking is very
important for your health. If you are pregnant or have recently had a baby, both you and your baby will benefit from your quitting smoking. This
study has very low risk. The only risk is that some people might feel a little uncomfortable about answering questions about their smoking habits.
Confidentiality: Your health care provider will collect some information about your health and smoking habits, and this will be shared with the
Department of Social Services (DSS) and its agents. The information will be kept confidential and used only by the DSS and its agent Yale University,
and the Centers for Medicare and Medicaid Services (CMS) and its agent RTI International. Yale University and RTI International will be studying this
program, so they will be given some information about your experience in the program. Neither Yale University nor RTI International will be given your
HUSKY Health identification number. Yale University will not be given your name or any other information that could be used to identify you. RTI
International will be given your name, address and phone number because they may need to contact you as part of the study. You may be asked to
be a part of a focus group (a group discussion) or to answer a survey about your experience. Both RTI International and Yale will also use health and
smoking information collected in this study to better understand how well incentives work to help people stop smoking.
Voluntary Participation: It is your choice whether to be in this study. You can decide not to take part in the study and you can leave the study at any
time and for any reason. Your choice about being in the study will not change your eligibility for HUSKY Health in any way.
Program Termination: Because this is a study, it is important that the information that is collected is complete and correct. DSS and its agents have the
right to end your participation in the study if DSS has reason to believe that the information collected from you is not complete or is misreported. For
example, if you do not answer most of the questions that we ask, or if you decline to answer any questions, DSS can end your participation in this study.
Smoking Cessation Information
8.
8.a
Did the provider counsel patient about the importance of quitting smoking?
Yes
No
8.b
Did the provider give patient general information about available smoking cessation treatment and services?
Yes
No
8.c
Would the patient like to actively engage in efforts to quit smoking?
Yes
No
If the answer to 8.c is YES, please complete and have the patient sign the Informed Consent form and check Option A.
If the answer to 8.c is NO, check Option B if willing to answer additional questions as part of the study, or
Option C if refuses services and does not wish to participate at all in the study.
REWARDS TO QUIT PROGRAM INFORMED CONSENT: To be completed and signed by the Patient.
Please submit the completed form by clicking the submit button at the end of the form, and retain the original in the Patient’s file.
Date (mmddyyyy):
Please mark one entry only. Please have Patient sign and enter date below:
Option A: I have read the above information and I agree to participate in this study by answering questions about my smoking
habits and other health-related information, and allowing information to be shared as described above. I also agree to take part
in quit smoking activities.
Option B: I have read the above information and I agree to participate in this study by answering questions about my smoking
habits and other health-related information, and allowing information to be shared as described above. I do not agree to take
part in quit smoking activities.
Option C: I have read the above information and I do not want to participate in this study. I understand that this will not affect
my eligibility for HUSKY Health.
Electronic Signature Agreement. By clicking “I agree” and signing below, you are signing this form electronically. You agree your electronic
signature authorizes the accuracy of content in this form.
I agree
Signature of Patient
Date (mmddyyyy)
Signature of Witness
Date (mmddyyyy)
I agree
IMPORTANT: Please read the instructions before submitting. By clicking the SUBMIT button, after saving this form, you certify that all
information provided in the application is accurate and correct. Clicking the submit button transmits the information to HUSKY Health.
SUBMIT
FORM023B REWARDS TO QUIT Program Referral Form
Revised 03.01.2014C-E
6