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Fax to Quit

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.

For additional information, contact the Department of Health Regional Primary Contractor in your area.