Provider Web Referral

State Selection

To refer a youth 13-17 years of age please contact Paola Klein at paola-klein@ouhsc.edu

We are sorry, your state isn't currently part of the My Life My Quit program. Please contact your local Department of Health for additional resources.

Thank you, unfortunately we are not able to move forward with your enrollment process. Please contact your school or local health department to complete the QuitLine Waiver process.

Patient Information

Patient’s first name

Patient’s last name

Patient’s DOB

To be referred to the My Life My Quit program you must be under 18 years old. If you are over 18 years old please call 1-800-Quit Now (1-800-784-8669) to speak with a QuitLine representative.

Primary phone type Select Cell Home Work

Patient’s primary phone

Extension

Secondary phone type Select Cell Home Work

Patient's secondary phone

Extension

Patient's address

Patient's address 2

Patient's city

Patient's state Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Patient's zip

Patient's preferred language

The patient has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, medication shipment, and quit anniversaries. The patient has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, and quit anniversaries.

• Yes
• No

Standard message and data rates may apply. The patient may opt-out at any time. Provider, please verify the youth patient is able to receive messages on the provided phone number.

Is it ok to leave a voicemail?

• Yes
• No

Is patient hearing impaired?

• Yes
• No

Patient's insurance provider

Insurance Member ID

Clinic Information

Type of HIPAA covered Entity:

Provider First Name

Provider Last Name

Contact First Name

Contact Last Name

Clinic/organization name

Clinic address

Clinic address 2

Clinic city

Clinic state Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Clinic zip code

Clinic Phone Number

How would you like to receive updates about your patient?

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Clinic fax number

Provider Email