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:
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).