Patient Referral Forms
There are two methods for referring a patient to a Quit Coach. All methods are HIPPA compliant:
- Web – the on-line Patient Referral Form
- 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 new 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 Teresa.Brown@dhhs.nh.gov.
Implementing QuitWorks-NH in your health system requires a change in workflow among staff. Ask for print materials in waiting rooms and on bulletin boards from QuitWorks-NH.
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!