Fax to Quit Referral Form

Information on the Pennsylvania Department of Health’s Fax to Quit Program:

All healthcare providers currently enrolled in the Pennsylvania Department of Health’s Fax to Quit Program are encouraged to complete the Every Smoker, Every Time Webinar and a webinar training on how to complete the fax referral form. Please click here for the webinar on completing the fax referral form.

If you are interested in participating in the Pennsylvania Department of Health’s Fax to Quit program please use this to obtain an overview of the program and instructions on how to enroll.