Fax to Quit
A Service of the PA Free
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
· 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
Benefits To the Referral Source
of tobacco user successfully quitting
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
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
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.