Provider Referral Form

Want to refer a patient to the Quitline? Please complete the provider referral form below

Step 1: Patient InformationStep 2: Clinic InformationStep 3: Authorization
Patient's first name *   Patient's address *  
Patient's last name *   Patient's address 2
Patient's DOB *     Patient's city *  
Patient's primary phone *   Patient's state *  
Primary phone type * Patient's zip *  
Patient's secondary phone Patient's preferred language *  
Secondary phone type Is it ok to leave a voicemail? *  
Best contact days * Is patient hearing impaired *  
Best contact times * Patient's insurance provider
Insurance Member ID