State Smoking Quitline Programs
PROVIDER REFERRAL FORM RESOURCES
Alaska
Website: http://alaskaquitline.com
State phone number: QUIT NOW (1-800-784-8669)
Fax Referral Form, English: http://dhss.alaska.gov/dph/Chronic/Documents/Tobacco/quitline/TobaccoFreeAlaska_FaxReferralForm_Cessation.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Alabama
Website: https://alabama.quitlogix.org/
State phone number: QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://alabama.quitlogix.org/files/pdf/AlabamaProviderRef.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://alabama.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
Arkansas
Website: http://www.stampoutsmoking.com
State phone number: QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.stampoutsmoking.com/wp-content/uploads/2015/03/Arkansas-Tobacco-Quitline-Fax-Referra-2015-New-fixed.pdf
Fax Referral Form, Spanish:
http://www.stampoutsmoking.com/wp-content/uploads/2014/09/Fax-Form-Spanish.pdf
Electronic Referral Form, English:
https://arkansas.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
Arizona
Website: http://ashline.org
State phone number: 1-800-55-66-222
Fax Referral Form, English:
http://ashline.org/documents/QuitFax-Referral-Form-updated.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.azwebquit.org/default.asp?healthcare
Electronic Referral Form, Spanish: Not available
Notes: Providers required to create an account:
http://ashline.org/documents/QuitFax_Instructions.pdf
California
Website: http://www.nobutts.org
State phone number:
English: 1-800-NO-BUTTS (1-800-662-8887)
Spanish: 1-800-45-NO-FUME (1-800-456-6386)
Fax Referral Form, English:
http://www2.massgeneral.org/ceasetobacco/pdf/California%20Helpline.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://forms-nobutts.org/referral/?utm_campaign=Track%20Outbound%20to%20Web%20Based%20Referral&utm_medium=Website&utm_source=Website&__hstc=99836545.905a8e7bfe8447a11f80604c26b25d27.1471463920727.1471463920727.1471463920727.1&__hssc=99836545.4.1471463920728&__hsfp=3975657949
Electronic Referral Form, Spanish: Not available
Colorado
Website: https://www.coquitline.org
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://www.coquitline.org/files/pdf/ColoradoQuitlineReferralFormEnglish.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.coquitline.org/eReferral/
Electronic Referral Form, Spanish: Not available
Connecticut
Website: http://www.ct.gov/dph/cwp/view.asp?a=3137&q=388064&dphNav=|&dphNav_GID=1841
State phone number: 860-509-8251
Fax Referral Form, English:
https://www.ctdhp.com/documents/connecticut_fax_referral_form_template_revised_10_24_11.pdf
Fax Referral Form, Spanish:
http://www.ct.gov/dph/lib/dph/hems/tobacco/pdf/ct_spanish_fax_referral_form_revised12-14docx.pdf
Electronic Referral Forms: Not available
Washington, DC
Website: https://smokefree.gov
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Forms: Not available
Electonic Referral Forms: Not available
Notes: Contact the DC Quitline for provider referral forms.
Delaware
Website: http://dhss.delaware.gov/dph/dpc/quitline.html
State phone number: 1-866-409-1858
Fax Referral Form, English:
https://www.healthydelaware.org/Content/Images/Marketing-Materials/Downloads/Quitline-Fax-Referral-Form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Florida
Website: http://www.tobaccofreeflorida.com
State phone number: 1-877-U-CAN-NOW (1-877-822-6669)
Fax Referral Form, English:
http://www.tobaccofreeflorida.com/wp-content/uploads/tff_provider_fax_referral_form.pdf
Fax Referral Form, Spanish:
http://www.tobaccofreeflorida.com/wp-content/uploads/ProviderTaxRefSPA.pdf
Electonic Referral Forms: Not available
Georgia
Website: https://dph.georgia.gov/ready-quit
State phone number: 1-877-270-STOP (877-270-7867)
Fax Referral Form, English:
https://dph.georgia.gov/sites/dph.georgia.gov/files/GTQL%20Fax%20Referral%20Form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Guam
Website: https://www.quitnow.net/guam/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form: Not available
Electonic Referral Forms: Not available
Hawaii
Website: http://hawaiiquitline.org/healthcare-providers/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://hawaiiquitline.org/wp-content/uploads/woocommerce_uploads/2014/10/HawaiiQuitline-Fax.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Iowa
Website: https://iowa.quitlogix.org
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://iowa.quitlogix.org/files/pdf/IOWA%20Fax%20Form2.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://iowa.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
Notes: Spanish Fax Referral Form is under construction.
Idaho
Website: https://www.quitnow.net/idaho/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.healthandwelfare.idaho.gov/Portals/0/Health/Disease/Tobacco/Healthcare%20Provider%20Fax%20Referral%20Form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Illinois
Website: http://quityes.org
State phone number: 1-866-QUIT-YES 1-866-784-8937
Fax & Electronic Referral Forms: After the healthcare provider has enrolled as a Quitline Referral Partner, training on integrating the referral process into clinical practice procedures and necessary referral forms will be provided by the ITQL.
Notes: Any healthcare provider, facility or system that provides healthcare services to tobacco users may enroll as a Quitline Referral Partner. Contact the local health department or the ITQL for additional information and assistance in enrolling.
Indiana
Website: http://www.in.gov/quitline/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.in.gov/quitline/files/QLfaxreferral.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Notes: To have direct referrals privileges it is required that providers register as a Preferred Provider: http://www.in.gov/quitline/2358.htm
Kansas
Website: http://www.kdheks.gov/tobacco/cessation.html
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.kdheks.gov/tobacco/cessation.html
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Notes: On homepage, click third link “Kansas Tobacco Quitline Fax Referral Form” to download the word document.
Kentucky
Website: https://www.quitnowkentucky.org
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://www.quitnowkentucky.org/files/pdf/QL_KY_FRF.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.quitnowkentucky.org/eReferral/
Electronic Referral Form, Spanish: Not available
Notes: Fax/electronic referral forms in Spanish are under construction.
Louisiana
Website: http://quitwithusla.org
State phone number: 225-342-9307
Fax Referral Form, English:
http://www.quitwithusla.org.php5-22.dfw1-1.websitetestlink.com/uploads/Fax_to_Quit_Referral_Form_Sample-1351000488.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Massachusetts
Website: http://makesmokinghistory.org/quit-now/what-is-the-helpline/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://quitworks.makesmokinghistory.org/uploads/section_quitworks/forms/QWReferralForm.pdf
Fax Referral Form, Spanish:
http://quitworks.makesmokinghistory.org/uploads/section_quitworks/forms/QWReferralForm-SP%20Updated.pdf
Electonic Referral Forms: Not available
Maryland
Website: http://smokingstopshere.com
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://smokingstopshere.com/wp-content/uploads/2014/10/Quitline_referral_form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Notes: Providers must receive training prior to using electronic referral forms:
http://smokingstopshere.com/ereferral-training/
Maine
Website: http://www.tobaccofreemaine.org/
State phone number: 1-800-207-1230
Fax Referral Form: Not available
Electonic Referral Forms: Not available
Michigan
Website: http://www.njhcommunity.org/michigan/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.njhcommunity.org/michigan/misc/MI-Prov-Ref.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Minnesota
Website: https://www.quitplan.com
State phone number: 1-888-354-PLAN (1-888-354-7526)
Fax Referral Forms: Not available
Electonic Referral Forms: Not available
Notes: Registration is required for providers: http://www.health.state.mn.us/callitquits
Missouri
Website: http://health.mo.gov/living/wellness/tobacco/smokingandtobacco/tobaccocontrol.php#quitline
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://health.mo.gov/living/wellness/tobacco/smokingandtobacco/pdf/faxreferralform.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Mississippi
Website: http://www.quitlinems.com
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.quitlinems.com/files/MS_Quitline_Provider_5-20-2015_Revision_1.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.iqhquitline.com/referrals/login.php
Electronic Referral Form, Spanish: Not available
Montana
Website: http://dphhs.mt.gov/publichealth/mtupp
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://dphhs.mt.gov/Portals/85/publichealth/documents/Tobacco/QuitLine/MT%20Provider%20Referral%20Form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
North Carolina
Website: http://www.quitlinenc.com
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.quitlinenc.com/docs/provider-resources/2016-fax-referral-form.pdf?sfvrsn=2
Fax Referral Form, Spanish:
http://www.quitlinenc.com/docs/provider-resources/2016-spanish-fax-referral-form.pdf?sfvrsn=2
Electonic Referral Forms: Not available
North Dakota
Website: https://ndquits.health.nd.gov
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.nd.gov/eforms/Doc/sfn59499.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Nebraska
Website: http://dhhs.ne.gov/Publichealth/pages/tfn_ces.aspx
State phone number: 402-471-2101
Fax Referral Form, English:
http://dhhs.ne.gov/publichealth/TFN%20Docs/21051%20TFN%20Quitline%20Fax%20Referral%20Form%20(5)FINAL.pdf
Fax Referral Form Instructions: http://dhhs.ne.gov/publichealth/TFN%20Docs/Fax%20Referral%20Instructions%20May%202016.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Nevada
Website: https://nevada.quitlogix.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://nevada.quitlogix.org/files/pdf/NevadaProviderRef.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://nevada.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
New Hampshire
Website: http://quitnownh.org/
State phone number: 866-657-8677
Fax Referral Form, English:
http://quitworksnh.org/wp-content/uploads/2016/05/QW-NH_Generic_2015.pdf
Fax Referral Form, Spanish:
http://quitworksnh.org/wp-content/uploads/2016/05/QWEnrollmentForm-spanish.pdf
Electonic Referral Forms: Not available
New Jersey
Website: http://www.njquitline.org/
State phone number:1-866-NJSTOPS (1-866-657-8677)
Fax Referral Form, English:
http://www.tobaccofreenj.com/wp-content/assets/NJ-Refer-to-Quit-Referral-Form-2012.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Notes: The quitline number is multilingual.
New Mexico
Website: http://www.quitnownm.com/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://nmtupac.com/remote.php?man=Tupac&fn=getFile&filekey=nmfaxreferralform
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
New York
Website: http://www.nysmokefree.com/
State phone number: 1-866-NY-QUITS (1-66-697-8487)
Fax Referral Form, English:
https://www.nysmokefree.com/Fax/Refer-to-QuitReferralForm2-11.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.nysmokefree.com/FaxToQuit/login.aspx?
Electronic Referral Form, Spanish: Not available
Notes: To use the electronic forms, providers have to register and create an ID and password.
North Carolina
Website: http://www.quitlinenc.com/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.quitlinenc.com/docs/provider-resources/2016-fax-referral-form.pdf?sfvrsn=2
Fax Referral Form, Spanish:
http://www.quitlinenc.com/docs/provider-resources/2016-spanish-fax-referral-form.pdf?sfvrsn=2
Electonic Referral Forms: Not available
North Dakota
Website: https://ndquits.health.nd.gov/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.nd.gov/eforms/Doc/sfn59499.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Ohio
Website: https://ohio.quitlogix.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Provider Referral, English:
https://ohio.quitlogix.org/files/pdf/Quitline_Ohio_FRF.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://ohio.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
Oklahoma
Website: http://okhelpline.com/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.pmtc.ok.gov/OMLRPFormHelpline.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Oregon
Website: http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/GetHelpQuitting/Pages/oregonquitline.aspx
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/State_FaxReferralForm_English.pdf
Fax Referral Form, Spanish:
http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/State_FaxReferralForm_Spanish_02-12-13.pdf
Electronic Referral Form, English:
https://www.wellbeingenroll.net/ProviderReferral/Default.aspx?clientName=oregon
Electronic Referral Form, Spanish: Not available
Pennsylvania
Website: http://www.health.pa.gov/my%20health/healthy%20living/smoke%20free%20tobacco/pages/pa-free-quitline.aspx#.vjem-jjd99a
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.health.pa.gov/My%20Health/Healthy%20Living/Smoke%20Free%20Tobacco/Documents/PA%20Provider%20Referral%20Form%20draft%20with%20signature%20line.pdf
Fax Referral Form, Spanish: http://www.health.pa.gov/My%20Health/Healthy%20Living/Smoke%20Free%20Tobacco/Documents/(new)PA%20Provider%20Referral%20Form%20draft(Spanish).pdf
Electonic Referral Forms: Not available
Puerto Rico
Website: http://www.salud.gov.pr/Sobre-tu-Salud/Pages/Tabaquismo.aspx
State phone number: 1-877-Déjalos (1-877-335-2567)
Fax Referral Form, English: Not available.
Fax Referral Form, Spanish:
http://www.salud.gov.pr/Sobre-tu-Salud/Documents/Fax%20to%20Quit%20-%20Referred.pdf
Electonic Referral Forms: Not available
Rhode Island
Website: https://ri.quitlogix.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://ri.quitlogix.org/files/pdf/QWEnrollmentForm_Eng.Rev.10.2015.pdf
Fax Referral Form, Spanish:
https://ri.quitlogix.org/files/pdf/RI_ReferralForm_Spanish.pdf
Electronic Referral Form, English:
https://ri.quitlogix.org/eReferral/
Electronic Referral Form, Spanish:
https://ri.quitlogix.org/eReferral/
South Carolina
Website: http://www.scdhec.gov/Health/TobaccoCessation/TobaccoQuitline/CalltheQuitlineNow/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.scdhec.gov/Library/d-1617.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
South Dakota
Website: http://sdquitline.com/
State phone number: 1-866-SD-QUITS (1-866-737-8487)
Fax Referral Form, English:
http://sdquitline.com/wp-content/uploads/2014/05/SDQLFaxReferralForm.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Tennessee
Website: http://www.tnquitline.com/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.tnquitline.com/assets/files/TN_fax_referral.pdf
Fax Referral Form, Spanish:
http://www.tnquitline.com/assets/files/TN_fax_referral_spanish.pdf
Electronic Referral Form, English:
https://www.iqhquitline.com/referrals/login.php
Electronic Referral Form, Spanish: Not available
Notes: Requires providers to register for electronic referral forms.
Texas
Website: http://www.dshs.texas.gov/tobacco/quityes.shtm
State phone number: 1-877-937-7848 (American Cancer Society)
Fax Referral Form, English:
http://www.yesquit.org/downloads/other_materials/TX_Fax%20Referral%20Form%20Update%2011.05.12.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
http://www.yesquit.org/referral-form/
Electronic Referral Form, Spanish: Not available
Utah
Website: http://waytoquit.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://waytoquit.com.s3.amazonaws.com/wp-content/uploads/20160915221125/UT_Fax_Referral_Form.pdf
Fax Referral Form, Spanish:
http://waytoquit.com.s3.amazonaws.com/wp-content/uploads/20160915220954/UT_Spanish_Fax_Referral_Form.pdf
Electronic Referral Form, English:
https://www.wellbeingenroll.net/ProviderReferral/Default.aspx?clientName=utah
Electronic Referral Form, Spanish: Not available
Vermont
Website: http://802quits.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://802quits.org/wordpress/wp-content/uploads/2015/11/BlankFaxReferralForm-FINAL-10-16-15.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Virginia
Website: https://www.quitnow.net/virginia/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Forms: Not available
Electonic Referral Forms: Not available
Washington
Website: http://www.doh.wa.gov/YouandYourFamily/Tobacco/HowtoQuit
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.doh.wa.gov/Portals/1/Documents/Pubs/340-221-FaxReferralForm.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
West Virginia
Website: http://www.bebetter.net/wvquitline_home.html
State phone number: 877-966-8784
Fax Referral Form, English:
http://www.bebetter.net/pdf/WVQuitline_Fax-To-QuitForm_2015.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Wisconsin
Website: http://www.ctri.wisc.edu/quitline.htm
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Spanish-language line: 1-877-266-3863
Fax Referral Forms: Not available
Electonic Referral Forms: Not available
Notes: There is no provider referral form. There is a consent form for referral:
http://www.ctri.wisc.edu/ql-providers-fax-to-quit.htm. Call UW-CTRI for more information at (608) 262-8673.
Wyoming
Website: https://wyo.quitlogix.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://wyo.quitlogix.org/files/pdf/WYProviderReferralForm06-2013.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://wyo.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
Website: http://alaskaquitline.com
State phone number: QUIT NOW (1-800-784-8669)
Fax Referral Form, English: http://dhss.alaska.gov/dph/Chronic/Documents/Tobacco/quitline/TobaccoFreeAlaska_FaxReferralForm_Cessation.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Alabama
Website: https://alabama.quitlogix.org/
State phone number: QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://alabama.quitlogix.org/files/pdf/AlabamaProviderRef.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://alabama.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
Arkansas
Website: http://www.stampoutsmoking.com
State phone number: QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.stampoutsmoking.com/wp-content/uploads/2015/03/Arkansas-Tobacco-Quitline-Fax-Referra-2015-New-fixed.pdf
Fax Referral Form, Spanish:
http://www.stampoutsmoking.com/wp-content/uploads/2014/09/Fax-Form-Spanish.pdf
Electronic Referral Form, English:
https://arkansas.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
Arizona
Website: http://ashline.org
State phone number: 1-800-55-66-222
Fax Referral Form, English:
http://ashline.org/documents/QuitFax-Referral-Form-updated.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.azwebquit.org/default.asp?healthcare
Electronic Referral Form, Spanish: Not available
Notes: Providers required to create an account:
http://ashline.org/documents/QuitFax_Instructions.pdf
California
Website: http://www.nobutts.org
State phone number:
English: 1-800-NO-BUTTS (1-800-662-8887)
Spanish: 1-800-45-NO-FUME (1-800-456-6386)
Fax Referral Form, English:
http://www2.massgeneral.org/ceasetobacco/pdf/California%20Helpline.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://forms-nobutts.org/referral/?utm_campaign=Track%20Outbound%20to%20Web%20Based%20Referral&utm_medium=Website&utm_source=Website&__hstc=99836545.905a8e7bfe8447a11f80604c26b25d27.1471463920727.1471463920727.1471463920727.1&__hssc=99836545.4.1471463920728&__hsfp=3975657949
Electronic Referral Form, Spanish: Not available
Colorado
Website: https://www.coquitline.org
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://www.coquitline.org/files/pdf/ColoradoQuitlineReferralFormEnglish.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.coquitline.org/eReferral/
Electronic Referral Form, Spanish: Not available
Connecticut
Website: http://www.ct.gov/dph/cwp/view.asp?a=3137&q=388064&dphNav=|&dphNav_GID=1841
State phone number: 860-509-8251
Fax Referral Form, English:
https://www.ctdhp.com/documents/connecticut_fax_referral_form_template_revised_10_24_11.pdf
Fax Referral Form, Spanish:
http://www.ct.gov/dph/lib/dph/hems/tobacco/pdf/ct_spanish_fax_referral_form_revised12-14docx.pdf
Electronic Referral Forms: Not available
Washington, DC
Website: https://smokefree.gov
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Forms: Not available
Electonic Referral Forms: Not available
Notes: Contact the DC Quitline for provider referral forms.
Delaware
Website: http://dhss.delaware.gov/dph/dpc/quitline.html
State phone number: 1-866-409-1858
Fax Referral Form, English:
https://www.healthydelaware.org/Content/Images/Marketing-Materials/Downloads/Quitline-Fax-Referral-Form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Florida
Website: http://www.tobaccofreeflorida.com
State phone number: 1-877-U-CAN-NOW (1-877-822-6669)
Fax Referral Form, English:
http://www.tobaccofreeflorida.com/wp-content/uploads/tff_provider_fax_referral_form.pdf
Fax Referral Form, Spanish:
http://www.tobaccofreeflorida.com/wp-content/uploads/ProviderTaxRefSPA.pdf
Electonic Referral Forms: Not available
Georgia
Website: https://dph.georgia.gov/ready-quit
State phone number: 1-877-270-STOP (877-270-7867)
Fax Referral Form, English:
https://dph.georgia.gov/sites/dph.georgia.gov/files/GTQL%20Fax%20Referral%20Form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Guam
Website: https://www.quitnow.net/guam/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form: Not available
Electonic Referral Forms: Not available
Hawaii
Website: http://hawaiiquitline.org/healthcare-providers/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://hawaiiquitline.org/wp-content/uploads/woocommerce_uploads/2014/10/HawaiiQuitline-Fax.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Iowa
Website: https://iowa.quitlogix.org
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://iowa.quitlogix.org/files/pdf/IOWA%20Fax%20Form2.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://iowa.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
Notes: Spanish Fax Referral Form is under construction.
Idaho
Website: https://www.quitnow.net/idaho/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.healthandwelfare.idaho.gov/Portals/0/Health/Disease/Tobacco/Healthcare%20Provider%20Fax%20Referral%20Form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Illinois
Website: http://quityes.org
State phone number: 1-866-QUIT-YES 1-866-784-8937
Fax & Electronic Referral Forms: After the healthcare provider has enrolled as a Quitline Referral Partner, training on integrating the referral process into clinical practice procedures and necessary referral forms will be provided by the ITQL.
Notes: Any healthcare provider, facility or system that provides healthcare services to tobacco users may enroll as a Quitline Referral Partner. Contact the local health department or the ITQL for additional information and assistance in enrolling.
Indiana
Website: http://www.in.gov/quitline/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.in.gov/quitline/files/QLfaxreferral.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Notes: To have direct referrals privileges it is required that providers register as a Preferred Provider: http://www.in.gov/quitline/2358.htm
Kansas
Website: http://www.kdheks.gov/tobacco/cessation.html
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.kdheks.gov/tobacco/cessation.html
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Notes: On homepage, click third link “Kansas Tobacco Quitline Fax Referral Form” to download the word document.
Kentucky
Website: https://www.quitnowkentucky.org
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://www.quitnowkentucky.org/files/pdf/QL_KY_FRF.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.quitnowkentucky.org/eReferral/
Electronic Referral Form, Spanish: Not available
Notes: Fax/electronic referral forms in Spanish are under construction.
Louisiana
Website: http://quitwithusla.org
State phone number: 225-342-9307
Fax Referral Form, English:
http://www.quitwithusla.org.php5-22.dfw1-1.websitetestlink.com/uploads/Fax_to_Quit_Referral_Form_Sample-1351000488.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Massachusetts
Website: http://makesmokinghistory.org/quit-now/what-is-the-helpline/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://quitworks.makesmokinghistory.org/uploads/section_quitworks/forms/QWReferralForm.pdf
Fax Referral Form, Spanish:
http://quitworks.makesmokinghistory.org/uploads/section_quitworks/forms/QWReferralForm-SP%20Updated.pdf
Electonic Referral Forms: Not available
Maryland
Website: http://smokingstopshere.com
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://smokingstopshere.com/wp-content/uploads/2014/10/Quitline_referral_form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Notes: Providers must receive training prior to using electronic referral forms:
http://smokingstopshere.com/ereferral-training/
Maine
Website: http://www.tobaccofreemaine.org/
State phone number: 1-800-207-1230
Fax Referral Form: Not available
Electonic Referral Forms: Not available
Michigan
Website: http://www.njhcommunity.org/michigan/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.njhcommunity.org/michigan/misc/MI-Prov-Ref.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Minnesota
Website: https://www.quitplan.com
State phone number: 1-888-354-PLAN (1-888-354-7526)
Fax Referral Forms: Not available
Electonic Referral Forms: Not available
Notes: Registration is required for providers: http://www.health.state.mn.us/callitquits
Missouri
Website: http://health.mo.gov/living/wellness/tobacco/smokingandtobacco/tobaccocontrol.php#quitline
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://health.mo.gov/living/wellness/tobacco/smokingandtobacco/pdf/faxreferralform.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Mississippi
Website: http://www.quitlinems.com
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.quitlinems.com/files/MS_Quitline_Provider_5-20-2015_Revision_1.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.iqhquitline.com/referrals/login.php
Electronic Referral Form, Spanish: Not available
Montana
Website: http://dphhs.mt.gov/publichealth/mtupp
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://dphhs.mt.gov/Portals/85/publichealth/documents/Tobacco/QuitLine/MT%20Provider%20Referral%20Form.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
North Carolina
Website: http://www.quitlinenc.com
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.quitlinenc.com/docs/provider-resources/2016-fax-referral-form.pdf?sfvrsn=2
Fax Referral Form, Spanish:
http://www.quitlinenc.com/docs/provider-resources/2016-spanish-fax-referral-form.pdf?sfvrsn=2
Electonic Referral Forms: Not available
North Dakota
Website: https://ndquits.health.nd.gov
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.nd.gov/eforms/Doc/sfn59499.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Nebraska
Website: http://dhhs.ne.gov/Publichealth/pages/tfn_ces.aspx
State phone number: 402-471-2101
Fax Referral Form, English:
http://dhhs.ne.gov/publichealth/TFN%20Docs/21051%20TFN%20Quitline%20Fax%20Referral%20Form%20(5)FINAL.pdf
Fax Referral Form Instructions: http://dhhs.ne.gov/publichealth/TFN%20Docs/Fax%20Referral%20Instructions%20May%202016.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Nevada
Website: https://nevada.quitlogix.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://nevada.quitlogix.org/files/pdf/NevadaProviderRef.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://nevada.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
New Hampshire
Website: http://quitnownh.org/
State phone number: 866-657-8677
Fax Referral Form, English:
http://quitworksnh.org/wp-content/uploads/2016/05/QW-NH_Generic_2015.pdf
Fax Referral Form, Spanish:
http://quitworksnh.org/wp-content/uploads/2016/05/QWEnrollmentForm-spanish.pdf
Electonic Referral Forms: Not available
New Jersey
Website: http://www.njquitline.org/
State phone number:1-866-NJSTOPS (1-866-657-8677)
Fax Referral Form, English:
http://www.tobaccofreenj.com/wp-content/assets/NJ-Refer-to-Quit-Referral-Form-2012.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Notes: The quitline number is multilingual.
New Mexico
Website: http://www.quitnownm.com/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://nmtupac.com/remote.php?man=Tupac&fn=getFile&filekey=nmfaxreferralform
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
New York
Website: http://www.nysmokefree.com/
State phone number: 1-866-NY-QUITS (1-66-697-8487)
Fax Referral Form, English:
https://www.nysmokefree.com/Fax/Refer-to-QuitReferralForm2-11.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://www.nysmokefree.com/FaxToQuit/login.aspx?
Electronic Referral Form, Spanish: Not available
Notes: To use the electronic forms, providers have to register and create an ID and password.
North Carolina
Website: http://www.quitlinenc.com/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.quitlinenc.com/docs/provider-resources/2016-fax-referral-form.pdf?sfvrsn=2
Fax Referral Form, Spanish:
http://www.quitlinenc.com/docs/provider-resources/2016-spanish-fax-referral-form.pdf?sfvrsn=2
Electonic Referral Forms: Not available
North Dakota
Website: https://ndquits.health.nd.gov/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.nd.gov/eforms/Doc/sfn59499.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Ohio
Website: https://ohio.quitlogix.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Provider Referral, English:
https://ohio.quitlogix.org/files/pdf/Quitline_Ohio_FRF.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://ohio.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
Oklahoma
Website: http://okhelpline.com/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.pmtc.ok.gov/OMLRPFormHelpline.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Oregon
Website: http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/GetHelpQuitting/Pages/oregonquitline.aspx
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/State_FaxReferralForm_English.pdf
Fax Referral Form, Spanish:
http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/State_FaxReferralForm_Spanish_02-12-13.pdf
Electronic Referral Form, English:
https://www.wellbeingenroll.net/ProviderReferral/Default.aspx?clientName=oregon
Electronic Referral Form, Spanish: Not available
Pennsylvania
Website: http://www.health.pa.gov/my%20health/healthy%20living/smoke%20free%20tobacco/pages/pa-free-quitline.aspx#.vjem-jjd99a
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.health.pa.gov/My%20Health/Healthy%20Living/Smoke%20Free%20Tobacco/Documents/PA%20Provider%20Referral%20Form%20draft%20with%20signature%20line.pdf
Fax Referral Form, Spanish: http://www.health.pa.gov/My%20Health/Healthy%20Living/Smoke%20Free%20Tobacco/Documents/(new)PA%20Provider%20Referral%20Form%20draft(Spanish).pdf
Electonic Referral Forms: Not available
Puerto Rico
Website: http://www.salud.gov.pr/Sobre-tu-Salud/Pages/Tabaquismo.aspx
State phone number: 1-877-Déjalos (1-877-335-2567)
Fax Referral Form, English: Not available.
Fax Referral Form, Spanish:
http://www.salud.gov.pr/Sobre-tu-Salud/Documents/Fax%20to%20Quit%20-%20Referred.pdf
Electonic Referral Forms: Not available
Rhode Island
Website: https://ri.quitlogix.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://ri.quitlogix.org/files/pdf/QWEnrollmentForm_Eng.Rev.10.2015.pdf
Fax Referral Form, Spanish:
https://ri.quitlogix.org/files/pdf/RI_ReferralForm_Spanish.pdf
Electronic Referral Form, English:
https://ri.quitlogix.org/eReferral/
Electronic Referral Form, Spanish:
https://ri.quitlogix.org/eReferral/
South Carolina
Website: http://www.scdhec.gov/Health/TobaccoCessation/TobaccoQuitline/CalltheQuitlineNow/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.scdhec.gov/Library/d-1617.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
South Dakota
Website: http://sdquitline.com/
State phone number: 1-866-SD-QUITS (1-866-737-8487)
Fax Referral Form, English:
http://sdquitline.com/wp-content/uploads/2014/05/SDQLFaxReferralForm.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Tennessee
Website: http://www.tnquitline.com/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.tnquitline.com/assets/files/TN_fax_referral.pdf
Fax Referral Form, Spanish:
http://www.tnquitline.com/assets/files/TN_fax_referral_spanish.pdf
Electronic Referral Form, English:
https://www.iqhquitline.com/referrals/login.php
Electronic Referral Form, Spanish: Not available
Notes: Requires providers to register for electronic referral forms.
Texas
Website: http://www.dshs.texas.gov/tobacco/quityes.shtm
State phone number: 1-877-937-7848 (American Cancer Society)
Fax Referral Form, English:
http://www.yesquit.org/downloads/other_materials/TX_Fax%20Referral%20Form%20Update%2011.05.12.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
http://www.yesquit.org/referral-form/
Electronic Referral Form, Spanish: Not available
Utah
Website: http://waytoquit.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://waytoquit.com.s3.amazonaws.com/wp-content/uploads/20160915221125/UT_Fax_Referral_Form.pdf
Fax Referral Form, Spanish:
http://waytoquit.com.s3.amazonaws.com/wp-content/uploads/20160915220954/UT_Spanish_Fax_Referral_Form.pdf
Electronic Referral Form, English:
https://www.wellbeingenroll.net/ProviderReferral/Default.aspx?clientName=utah
Electronic Referral Form, Spanish: Not available
Vermont
Website: http://802quits.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://802quits.org/wordpress/wp-content/uploads/2015/11/BlankFaxReferralForm-FINAL-10-16-15.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Virginia
Website: https://www.quitnow.net/virginia/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Forms: Not available
Electonic Referral Forms: Not available
Washington
Website: http://www.doh.wa.gov/YouandYourFamily/Tobacco/HowtoQuit
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
http://www.doh.wa.gov/Portals/1/Documents/Pubs/340-221-FaxReferralForm.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
West Virginia
Website: http://www.bebetter.net/wvquitline_home.html
State phone number: 877-966-8784
Fax Referral Form, English:
http://www.bebetter.net/pdf/WVQuitline_Fax-To-QuitForm_2015.pdf
Fax Referral Form, Spanish: Not available
Electonic Referral Forms: Not available
Wisconsin
Website: http://www.ctri.wisc.edu/quitline.htm
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Spanish-language line: 1-877-266-3863
Fax Referral Forms: Not available
Electonic Referral Forms: Not available
Notes: There is no provider referral form. There is a consent form for referral:
http://www.ctri.wisc.edu/ql-providers-fax-to-quit.htm. Call UW-CTRI for more information at (608) 262-8673.
Wyoming
Website: https://wyo.quitlogix.org/
State phone number: 1-800-QUIT NOW (1-800-784-8669)
Fax Referral Form, English:
https://wyo.quitlogix.org/files/pdf/WYProviderReferralForm06-2013.pdf
Fax Referral Form, Spanish: Not available
Electronic Referral Form, English:
https://wyo.quitlogix.org/eReferral/
Electronic Referral Form, Spanish: Not available
