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Skip Navigation LinksPennsylvania Department of Health > My Health > Healthy Living > Smoke-Free / Tobacco > Fax to quit Program

Fax to Quit Program

A Service of the PA Free Quitline 

Information for Referral Sources: 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:  


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).
Benefits To the Referral Source
·         Increases likelihood of tobacco user successfully quitting
·         Integrates Quitline into treatment plan
·         Provides faxed patient progress reports back to referral sources (HIPAA covered entities only)
·         Provides tobacco user with support when needed most, 24 hours a day
·         Studies show that using brief intervention, along with phone counseling and medication, greatly increases the odds of a tobacco user successfully quitting   tobacco.  
Benefits to the Tobacco User 
·         Coaching available seven days per week
·         Up to five proactive coaching sessions with Quitline Coach with unlimited inbound calls to be made by the tobacco user
·         Self-assessment with personalized feedback to enhance motivation and commitment
·         Tobacco user involved with review of quit plan and establishment of quit date
·         Education for tobacco user on use of approved or prescribed quit smoking medicine
·         Nicotine replacement therapy for eligible participants if available
·         Self-help quit guide and tailored fact sheets sent to tobaco user by mail
·         The Quitline is also effective for spit tobacco users.