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

  1. Fax – using a paper Patient Referral Form
  2. Web – the on-line Patient Referral Form
  3. 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

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 Teresa.  These easy-to-read rack cards give information how a patient may contact a Quit Coach from their phone by calling 1-800-QUIT-NOW, on their schedule. Visiting is a convenient way to view services and access educational resources.


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.