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How to Refer Patients
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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?
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Other
{{utahWaver}}
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.
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
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Patient’s primary phone
Secondary phone type
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Work
Patient's secondary phone
Best contact days
Best contact times
Patient's address
Patient's address 2
Patient's city
Patient's state
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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.
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
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How would you like to receive updates about your patient?
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Clinic fax number
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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.
Notice of Nondiscrimination and Program Accessibility Information
Please print and give to patient.