Provider Web Referral

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

Best contact days

Best contact times

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

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

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

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.