Patient Referral Forms

As a provider, your brief intervention is the best motivator for your patient to quit tobacco use. Each intervention is a dose, that over time will elicit a ‘desire to quit’ response from your patient. However, QuitWorks-NH services will reach out to all referred patients regardless of the stage of readiness to quit. If your office is interested in becoming a participant in QuitWorks-NH, please contact Teresa Brown at (603) 271-8949 or electronically at

Is your healthcare system certified for the EHR Incentive Program Stage 2 or later? All healthcare systems participating in the electronic health referral (EHR) Incentive Program are required to use such EHRs beginning 2015. The new NAQC guide includes an important discussion on how eReferral systems can be used by healthcare systems to meet performance measures for the EHR Incentive Program, as well as for the Joint Commission, PQRS and HEDIS. IF a healthcare system is planning to upgrade from a Stage 1 to a Stage 2 certified EHR, it is recommended that the provider wait for an operational Stage 2 EHR before building a bi-directional e-referral system (QuitWorks-NH is ready to be a bi-directional eReferral in your healthcare system when you are ready!)

Green ArrowUniversal Referral Form

At the heart of the QuitWorks-NH program is a generic, universally endorsed referral form.

Download our universal enrollment form in English
Download our universal enrollment form in Spanish

This universal form can be used by any provider with any patient, regardless of health insurance status. Pediatricians can also use the universal form with a child’s parent or guardian if they use tobacco.

Providers in office practices and in many health care facilities should download the universal enrollment form and reproduce it for their use.

If your office is interested in becoming a participant in QuitWorks-NH, contact Teresa Brown at 603-271-8949 or electronically at

Read about special features of the QuitWorks-NH referral form.

Green ArrowCustomized Referral Forms for Hospitals, Health Centers and Public Health Programs

Many health centers, clinics, and hospitals in New Hampshire have a customized QuitWorks enrollment form. Check below for a customized form for your facility. If you would like to customize QuitWorks for your facility, please contact us.

star I would like to have someone contact me about a ‘Customized Referral Form’ for my location.