My Life My Quit - Provider Web Referral

Patient Information

Patient’s first name

Patient’s last name

Patient’s DOB

Primary phone type

Primary Phone

Extension

Secondary phone type

Secondary Phone

Extension

Patient's address

Patient's address 2

Patient's city

Select State

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

Standard message and data rates may apply. The patient may opt-out at any time.

Is it ok to leave a voicemail?

Yes

Does the patient require accommodation while participating in the program such as TTY, translator, or relay service?

Yes

If yes, please specify:

Provider Information

Clinic Information

Type of HIPAA covered Entity:

Provider First Name

Provider Last Name

Contact First Name

Contact Last Name

Clinic/organization name

Clinics

National Provider Identifier (NPI)

Clinic address

Clinic address 2

Clinic city

Clinic state

Clinic zip code

Clinic Phone Number

How would you like to receive updates about your patient?

Fax

Clinic fax number

Provider Email

Authorization

As a HIPAA covered entity, I am authorized to receive personal health information for the individual being referred

By submitting this form, I verify that the patient being referred has consented to participate in the tobacco cessation program.

Authorization

As a Not Covered Entity, personal health information will not be shared back for the individual being referred.

By submitting this form, I verify that the patient being referred has consented to participate in the tobacco cessation program.

Provider Web Referral

State Selection

Patient Information

Provider Information

How would you like to receive updates about your patient?

Authorization

Authorization