Quit Now Indiana makes it easy for providers to help their patients stop smoking. The Fax Referral Program is as simple as click, fill out the form and fax to the Indiana Tobacco Quitline. This is a confidential service.
Discuss medication options with your patient
Print the Fax Referral form and fill out the form with your patient
Please include your name and fax number in the provider section.
Have your patient initial and sign the fax referral form for consent as required by HIPAA in the patient section.
Assist your patient in selecting the best time frame for the Quitline to call
Fax the form to: 1-800-483-3114
Prescribe pharmacotherapy if appropriate
A Quit Coach will call the patient
Evaluate the quit attempt with a follow-up
No limit on patients referrals from healthcare providers
Fax referrals are this simple! The Indiana Tobacco Quitline will send a report to your office for the patient's file. The report will tell you whether or not the patient was reached, enrolled in services and planned to quit.
The 3-Click Online Referral Portal
Research shows that 70% of all smokers want to quit. In many cases, people need professional help to succeed. If a physician advises a patient to quit just one time, it increases their chance for success.
1.800.Quit.Now is a frontline tool for helping tobacco users break their addiction. The quitline is free, it’s effective and it’s confidential. Thousands of people have used this service.
The 3-Click Online Referral Tool is free to use, and there is no charge to those who use tobacco. QuitNowReferral.com is a fast and easy way to get those who use tobacco on the path to a tobacco-free life. User guide.
Part of the Indiana Tobacco Quitline
electronic referral system
Healthcare providers can electronically refer patients to the Indiana Tobacco Quitline. Electronic Health Records (EHRs) represent an important new way for the Indiana Tobacco Quitline to receive referrals from healthcare providers. QNI staff is available to help healthcare systems plan and implement an EHR referral system for seamless processing and reporting. For further information, please email email@example.com or call 317-234-1787.
Refer patients to 1.800.Quit.Now. Professional Quit Coaches®
will help them quit at their own pace. No lectures. No pressure.