Fax to Quit
Information for Referral Sources
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.
For additional information, contact the Department of Health Regional Primary Contractor in your area.