Provider Web Referral

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

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.

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

Patient’s primary phone

Extension

Secondary phone type

Patient's secondary phone

Extension

Patient's address

Patient's address 2

Patient's city

Patient's state

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.

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?

Is patient hearing impaired?

Patient's insurance provider If a specific Medicaid insurance is not selected, we will not be able to connect the patient with additional Medicaid cessation benefits. Please select a specific Medicaid insurance if possible.

Insurance Member ID

Please select Nebraska Medicaid eligibility:

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.