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State Selection
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Patient Information
Patient’s first name
The American Indian Commercial Tobacco Program is only available to participating states. In which state does your patient currently live?
Select
Arizona
Colorado
Idaho
Iowa
Kansas
Massachusetts
Michigan
Minnesota
Missouri
Montana
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Pennsylvania
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Patient’s DOB
Primary phone type
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Patient's address
Patient's address 2
Patient's city
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
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Iowa
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Kentucky
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Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New York
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Ohio
Oklahoma
Oregon
Pennsylvania
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
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Patient's zip
Patient's preferred language
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Other
Hawaiian
Chamorro
The patient has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, and quit anniversaries.
Yes
No
Standard message and data rates may apply. The patient may opt-out at any time.
Is it ok to leave a voicemail?
Yes
No
Does the patient require accommodation while participating in the program such as TTY, translator, or relay service?
Yes
No
If yes, please specify:
Provider Information
Clinic Information
Type of HIPAA covered Entity:
Select
Healthcare Provider
Health Plan
Healthcare Clearing House
Not Covered Entity
Provider First Name
Provider Last Name
Contact First Name
Contact Last Name
Clinic/organization name
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Allina Health New Ulm Medical Center
Altru Clinic - Crookston
Avera Medical Group Granite Falls
Benton County Public Health
Cass County Health, Human & Veterans Services
Chisago County Public Health WIC Program
Chisago County Public Health FHV Program
Countryside Public Health Chippewa County
Countryside Public Health Swift County
Cuyuna Regional Medical Center
Entira Family Clinics Como/Roseville
Essentia Health - Ely Clinic
Fairview
HealthPartners Clinic Apple Valley
HealthPartners Clinic Arden Hills
HealthPartners Clinic Bloomington
HealthPartners Clinic St. Paul Como
HealthPartners Clinic St. Paul Midway
HealthPartners Clinic St. Paul Wabasha
HealthPartners Dental Clinic St. Paul Midway
HealthPartners Health Center for Women
Hennepin Healthcare
Horizon Public Health - Glenwood
Hubbard County Human Services
Indian Health Board of MPLS
Lakeville Clinic - Northfield Hospital & Clinics
M Health Fairview Clinic - Bethesda
Meeker Memorial Hospital
Methodist Hospital
myHealth for Teens & Young Adults
Neighborhood HealthSource Central Clinic
Neighborhood HealthSource Fremont Clinic
Neighborhood HealthSource North Metro Clinic
Neighborhood HealthSource Sheridan Clinic
Northern Dental Access Center - Bemidji
Oak Park Dental
Oakdale OBGYN Clinics - Maple Grove
Owatonna Hospital Mental Health Unit
Park Nicollet Clinic Champlin
Park Nicollet Clinic Minneapolis
Park Nicollet Clinic Plymouth
Park Nicollet Clinic and Specialty Center Burnsville
Park Nicollet Clinic and Specialty Center St. Louis Park
Park Nicollet Clinic Brooklyn Center Brookdale
Park Nicollet Same Day Surgery Center Maple Grove
Park Nicollet Specialty Center at Methodist Hospital
People Incorporated Family Life Mental Health Clinic
Sanford Canby Medical Center
Sanford Health Detroit Lakes Clinic & Same Day Surgery Center
Sanford Health Pelican Rapids Clinic
Sanford Luverne Clinic
Sanford Moorhead Campus
Sanford Worthington Medical Center
Stearns County Public Health
University of Minnesota Medical School
University of MN School of Dentistry
Clinic/organization name
Clinics
Select
Allina Health New Ulm Medical Center
Altru Clinic - Crookston
Avera Medical Group Granite Falls
Benton County Public Health
Cass County Health, Human & Veterans Services
Chisago County Public Health WIC Program
Chisago County Public Health FHV Program
Countryside Public Health Chippewa County
Countryside Public Health Swift County
Cuyuna Regional Medical Center
Entira Family Clinics Como/Roseville
Essentia Health - Ely Clinic
Fairview
HealthPartners Clinic Apple Valley
HealthPartners Clinic Arden Hills
HealthPartners Clinic Bloomington
HealthPartners Clinic St. Paul Como
HealthPartners Clinic St. Paul Midway
HealthPartners Clinic St. Paul Wabasha
HealthPartners Dental Clinic St. Paul Midway
HealthPartners Health Center for Women
Hennepin Healthcare
Horizon Public Health - Glenwood
Hubbard County Human Services
Indian Health Board of MPLS
Lakeville Clinic - Northfield Hospital & Clinics
M Health Fairview Clinic - Bethesda
Meeker Memorial Hospital
Methodist Hospital
myHealth for Teens & Young Adults
Neighborhood HealthSource Central Clinic
Neighborhood HealthSource Fremont Clinic
Neighborhood HealthSource North Metro Clinic
Neighborhood HealthSource Sheridan Clinic
Northern Dental Access Center - Bemidji
Oak Park Dental
Oakdale OBGYN Clinics - Maple Grove
Owatonna Hospital Mental Health Unit
Park Nicollet Clinic Champlin
Park Nicollet Clinic Minneapolis
Park Nicollet Clinic Plymouth
Park Nicollet Clinic and Specialty Center Burnsville
Park Nicollet Clinic and Specialty Center St. Louis Park
Park Nicollet Clinic Brooklyn Center Brookdale
Park Nicollet Same Day Surgery Center Maple Grove
Park Nicollet Specialty Center at Methodist Hospital
People Incorporated Family Life Mental Health Clinic
Sanford Canby Medical Center
Sanford Health Detroit Lakes Clinic & Same Day Surgery Center
Sanford Health Pelican Rapids Clinic
Sanford Luverne Clinic
Sanford Moorhead Campus
Sanford Worthington Medical Center
Stearns County Public Health
University of Minnesota Medical School
University of MN School of Dentistry
National Provider Identifier (NPI)
Clinic address
Clinic address 2
Clinic city
Clinic state
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Clinic zip code
Clinic Phone Number
How would you like to receive updates about your patient?
Fax
Email
Clinic fax number
Provider Email
Authorization
As a HIPAA covered entity, I am authorized to receive personal health information for the individual being referred
By submitting this form, I verify that the patient being referred has consented to participate in the tobacco cessation program.
Authorization
As a Not Covered Entity, personal health information will not be shared back for the individual being referred.
By submitting this form, I verify that the patient being referred has consented to participate in the tobacco cessation program.
Thank You
Thank you for the referral.
The Quitline will call your patient within 24 hours.
Free and confidential help to quit.
855-5AI-QUIT