Montana Tobacco Use Prevention Program
These materials are available for any health care provider who has patients that are interested in quitting the use of tobacco. If you have any questions or need any materials please contact Jeremy Brokaw at 406-444-5687 or firstname.lastname@example.org
Fax Referral Form is available for providers to use when they have a patient who is interested in quitting tobacco and using the Quit Line for assistance doing so. The form must be completely filled out and singed by both the provider and the patient. Once this is done, the form must be faxed to 1-800-261-6259. Once the fax has been received the Quit Line will then call the patient and give them some information regarding the FREE services that are offered. If the patient chooses to enroll in the program and successfully completes it, the provider will receive a fax letting them know that their patient has been successful.
A quick and easy reference for providers about the steps that their patients as well as the provider can take in order for the patient to receive FREE NRT (gum, patches, lozenges) and reduced cost Chantix from the Montana Tobacco Quit Line.