Provider Web Referral

Notice of Nondiscrimination and Program Accessibility Information
Please print and give to patient.

State Selection

The American Indian Commercial Tobacco Program is only available to participating states. In which state does your patient currently live? The My Life My Quit program is only available to participating states. In which state does your patient currently live?

Yes No

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.

Secondary phone type

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.

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?

Does the patient consent 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. 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?

Insurance Member ID Medicaid insurance member ID must be 11 digits, no other letters or symbols.

Please select Nebraska Medicaid eligibility:

Patient's Gender

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Is the patient pregnant?

How would you like to receive updates about your patient?

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Clinic fax number

Provider Email

Authorization

As a HIPAA covered entity, I am authorized to receive personal health information for the individual being referred.

By submitting this form, I verify that the patient being referred has consented to participate in the tobacco cessation program.

As a Not Covered Entity, personal health information will not be shared back for the individual being referred.

By submitting this form, I verify that the patient being referred has consented to participate in the tobacco cessation program.

Requested Pharmacotherapy:

*Patient gives permission to the Nebraska Tobacco Quitline to share information with their provider for the purposes of their health care treatment.

We can not submit the referral unless the patient consents to be referred to the Quitline.

*Patient gives permission to the Nebraska Tobacco Quitline to share information with their Heritage Health providers for the purposes of their health care treatment.

We will not be able to connect the patient with additional Medicaid cessation benefits.

Who provided the consent?

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Notice of Nondiscrimination and Program Accessibility Information
Please print and give to patient.

Provider Web Referral

Thank you for the referral. The Quitline will call your patient within 24 hours.

State Selection

Authorization

Thank you for the referral.
The Quitline will call your patient within 24 hours.