Begin Main Content Area

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).