Fax to Quit

The Fax To Quit Program allows healthcare and non-healthcare professionals to refer tobacco-using individuals to PA Free Quitline services for expert, evidence-based and confidential coaching to become tobacco-free.

Patient Fax Referral Forms

• Form with provider signature line (to be used by healthcare professionals with authority to prescribe medicine)
• Form without provider signature line (to be used by healthcare and non-healthcare professionals who may not prescribe medicine)
• Spanish language form with provider signature line
• Form for Non-healthcare Providers (Community Organizations)    

How Fax to Quit Works

• Conduct a brief intervention to determine the tobacco user's readiness to quit tobacco.
• Fill out the Fax to Quit referral form to enroll the tobacco user in Quitline services.
• Fax the Referral Form to PA Free Quitline.  Quitline staff will contact the tobacco user within 48 hours.
• Referral source will receive confirmation of contact and fax-back reports on patient progress (HIPAA-covered entities only).
  • View the Fax to Quit Referral Process Training