Healthcare providers can offer their patients the services of the Tobacco Quitline as the next step in helping them quit. The Consent/Referral form is HIPAA approved and allows the Tobacco Quitline to contact the patient instead of waiting for the patient to call or visit the Web site. The form also specifies that the patient will allow follow up and progress information to be given to the healthcare provider that will become part of their chart and can be reviewed on each visit.
Working together, we can help patients take advantage of professional, trained staff who will help with a quit plan, quit date and counseling. Healthcare providers can rely on the Tobacco Quitline to engage the patient and provide the behavior change counseling that can help them succeed.
If a caller or online user reports a medical condition that could inhibit or question the use of nicotine therapy replacement (NRT) product, a medical clearance form is sent to the caller's healthcare provider. In these cases, NRT will not be distributed without a medical clearance form signed and returned by the healthcare provider.
Pregnant callers who request the use of nicotine patches will be required to provide the name and contact information of their primary care physician. A special form is faxed to the provider to include the approval/denial of use of nicotine replacement. The Tobacco Quitline requires the form to be completed as a prescription for the specific product and dosage approved for use by the pregnant caller. No nicotine replacement product will be distributed to any pregnant caller without receipt of this approval.
Click here for the Online Referral Form or to become a registered healthcare provider.
Click here for the Fax Referral Form. (Spanish Fax/Referral Form)
Click here for the Online Referral Form or to become a registered healthcare provider.
Remember, any Alabamian can use the FREE phone or online counseling services and receive 4 weeks of FREE Nicotine Replacement Therapy patches (if medically eligible and enrolled in counseling) provided by Alabama QUITNOW. Call 1-800-QUITNOW or 1-800-784-8669 or for online counseling click here
Hours of Operation
Monday through Friday - 8 a.m. - 8 p.m.
Saturday - 9 a.m. - 5:30 p.m.
Sunday and after hours - Voicemail is available
Days of Operation
The Alabama Tobacco Quitline is open Monday through Saturday except for recognized holidays: Christmas Eve, Christmas Day, Martin Luther King Jr. Day, Memorial Day, Fourth of July, Labor Day, and Thanksgiving Day.
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