Fax-To-Quit Program

The Fax-To-Quit Program refers patients to the Colorado QuitLine using a fax referral form.

Referral Form

The Fax-to-Quit program offers healthcare providers a quick and efficient way to refer their patients to an evidence-based cessation service: The Colorado QuitLine.
Healthcare providers should refer any patient who indicates a readiness to quit in the next 30 days.
The Colorado QuitLine offers confidential tobacco cessation coaching and free nicotine patches to those medically eligible.

Healthcare providers fax the completed QuitLine Fax-to-Quit referral form to 1-800-261-6259.
Patients receive a call from the QuitLine to enroll them in the program and schedule up to five personalized behavioral coaching sessions.
Patients who are medically eligible receive a free supply of nicotine replacement therapy by mail.
Information about the patient’s enrollment status is faxed back to the healthcare provider.

If you are working with a Medicaid client, provide patient with a prescription for a smoking cessation product. All FDA-approved prescription medications and over-the-counter smoking cessation products are covered by Medicaid (maximum of two 90-day supplies per year).
Submit the Medicaid Prior Authorization Form by fax to the Prior Authorization Help Desk at 1-888-772-9696 or call 1-800-365-4944 to receive approval.
Fax the Patient Referral Form to the Colorado QuitLine at 1-800-261-6259. Copies of the form are available at www.cohealthproviders.com. Patients may also call 1.800.QUIT.NOW (1-800-784-8669).

For questions and additional information, please contact CCGC at (720) 297-1681.