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Healthcare providers interested in a quick and secure way to refer patients may use our fax referral program. The fax referral form is compliant with HIPAA regulations, confidential and easy to use. Once you and your patient sign the form, it can be faxed to the Tobacco Quitline so that staff can contact the patient. Regular progress reports are available to the healthcare provider, if requested, and will keep you informed on the patients efforts to quit tobacco. For more information contact the Mississippi Tobacco Quitline at 1-800-784-8669.
Click here for the Online Referral Form or to become a registered healthcare provider.
Click here to download a Medical Clearance Form (If Pregnant) (PDF Format)
Click here to download a Medical Clearance Form (If Pregnant) (Word Document Format)
Click here for the Fax Referral Form. (PDF Format)
Call 1-800-QUITNOW or 1-800-784-8669 Or For Free Online Support Click Here
Hours of Operation
Monday through Thursday - 7 a.m. - 9 p.m.
Friday - 7 a.m. - 7 p.m.
Saturday - 9 a.m. - 5:30 p.m.
Sunday - Voicemail is available
Days of Operation
The Mississippi 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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