* = Required
Thank you for the referral.
The Quitline will call your patient within 24 hours.
Submit Another Form
State Selection
The American Indian Commercial Tobacco Program is only available to participating states. In which state does your patient currently live?
The My Life My Quit program is only available to participating states. In which state does your patient currently live?
SELECT
Online Only
Phone + Online
Other
{{utahWaver}}
Yes
No
We are sorry, your state isn't currently part of the My Life My Quit program. Please contact your local Department of Health for additional resources.
Thank you, unfortunately we are not able to move forward with your enrollment process. Please contact your school or local health department to complete the QuitLine Waiver process.
Patient Information
Patient’s first name
Patient’s last name
Patient’s DOB
To be referred to the My Life My Quit program you must be under 18 years old. If you are over 18 years old please call 1-800-Quit Now (1-800-784-8669) to speak with a QuitLine representative.
Primary phone type
Select
Cell
Home
Work
Patient’s primary phone
Extension
Secondary phone type
Select
Cell
Home
Work
Patient's secondary phone
Extension
Patient's address
Patient's address 2
Patient's address 2
Patient's state
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Patient's zip
Patient's preferred language
The patient has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, and quit anniversaries.
Yes
No
Standard message and data rates may apply. The patient may opt-out at any time.
Provider, please verify the youth patient is able to receive messages on the provided phone number.
Is it ok to leave a voicemail?
Yes
No
The patient has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, medication shipment, and quit anniversaries.
Yes
No
Standard message and data rates may apply. The patient may opt-out at any time.
Provider, please verify the youth patient is able to receive messages on the provided phone number.
Is it ok to leave a voicemail?
Yes
No
The patient has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, and quit anniversaries.
Yes
No
Standard message and data rates may apply. The patient may opt-out at any time.
Provider, please verify the youth patient is able to receive messages on the provided phone number.
Is it ok to leave a voicemail?
Yes
No
The patient has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, and quit anniversaries.
Yes
No
Standard message and data rates may apply. The patient may opt-out at any time.
Provider, please verify the youth patient is able to receive messages on the provided phone number.
Is it ok to leave a voicemail?
Yes
No
Does the patient require accommodation while participating in the program such as TTY, translator, or relay service?
Yes
No
If yes, please specify:
Patient's insurance provider
If a specific Medicaid insurance is not selected, we will not be able to connect the patient with additional Medicaid cessation benefits. Please select a specific Medicaid insurance if possible.
Insurance Member ID
Insurance Member ID
Medicaid insurance member ID must be 11 digits, no other letters or symbols.
Please select Nebraska Medicaid eligibility:
{{item.InsurancePlan}}
Patient's Gender
{{i.Label}}
Is the patient pregnant?
Yes
No
{{ClinicInformationTitle}}
{{HIPPAEntityLabel}}
Provider First Name
Provider Last Name
Contact First Name
Contact Last Name
Clinic/organization name
Clinic/organization name
Clinics
{{c.ClinicName}}