Patient Referral Forms

As a provider, your brief intervention is the best motivator for your patient to quit using tobacco. Each intervention is a dose, which over time will elicit a ‘desire to quit’ response from your patient.

There are two methods for referring a patient to a Quit Coach.  All methods are HIPPA compliant:

  1. Web – the on-line Patient Referral Form
  2. E-Referral – utilizing Stage 2 Meaningful Use EMR interface with the Quit Coaches. E-Referral 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. The NAQC guide includes an important discussion on how, or contact NH Tobacco Prevention & Cessation Program for technical assistance.

Referring a patient to QuitWorks-NH services triggers a Quit Coach to reach out by phone to your patient within 2 days.

IMPORTANT:  Caller I.D. from Quit Coaches is 1-800-784-8669.  Most people do not answer 1-800 numbers of any sorts.  Therefore, if your patient uses a cell phone, encourage them to put “Quit Coach” into their list of contacts.  Quit Coaches can assist only if the patient answers the phone.

If your office is interested in becoming a participant in QuitWorks-NH, please contact NH Tobacco Prevention & Cessation Program (Teresa Brown) at (603) 271-8949 or electronically at

Implementing QuitWorks-NH in your health system requires a change in workflow among staff. Order free print materials to give to your patients and display in your practice!

Refer Your Patients to a Quit Coach

Submit a Provider Web Referral or E-Referral through the EMR.
Choose the most convenient method for YOUR practice!