Refer a Patient

Healthcare providers understand the many health risks and negative impacts that smoking and other tobacco use can have on the patients they care for. Physicians and other healthcare professionals across the state regularly refer patients to the Mississippi Tobacco Quitline to help their patients through our smoking cessation program and services.

We’re here to help. The Mississippi Tobacco Quitline provides several convenient ways for healthcare providers to refer patients to our evidence-based tobacco treatment services.

Fax Referral Form: English or Spanish

Download the form by clicking on the appropriate one, and fax it to 1-800-692-9023. The quitline will attempt contact with your patients for enrollment in quitline services. Progress reports are available upon request.

Download: English

Download: Spanish

Online Referral Portal

Click here to refer your patients through a secure online portal.

The quitline will attempt contact with your patients for enrollment in
quitline services. Progress reports are also available through the portal.

Electronic Health Records Referral

The Mississippi Tobacco Quitline can partner with interested healthcare providers or systems to develop an eReferral program through patients’ electronic health records. For more information, call 1-800-Quit-Now (1-800-784-8669) and press option #3.