FAX-TO-QUIT Referral Form Referred By - wvde state wv 2026

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  1. Click ‘Get Form’ to open the FAX-TO-QUIT Referral Form in the editor.
  2. Begin by entering today’s date in the designated field at the top of the form.
  3. In the 'Referred By' section, select your role from the options provided, such as Coach, Teacher, or Counselor. If your role is not listed, specify it in the 'Other' field.
  4. Fill out the Participant Consent and Personal Information Section. Ensure you print the participant's name clearly and provide a signature if applicable.
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Call 1-800-QUIT-NOW to ask about free or reduced-cost quit medicines. Quit coaches can help connect you with quit-smoking medicines through community programs. They may also be able to provide you with free medicines directly, for example by sending some nicotine patches, lozenges, or gum to your home.
All FDA-approved tobacco cessation medications are covered with a doctors prescription, including combination nicotine replacement therapy. For more information contact your health plan or consult your plans brochure.
Nicotine replacement therapy and other smoking cessation agents are covered for all Medicaid members enrolled in one of the telephone coaching programs associated with their Medicaid coverage.

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How gloji will help you be smoke free Quit aids e.g. patches, vapes and gum delivered to your door. Support from fully trained, friendly stop smoking mentors. 12 weeks of interactive videos. Online articles, tips and guides. Boost your fitness with online gym classes in gloji gym.
Some West Virginians are eligible to receive free phone coaching services and free nicotine replacement products through the West Virginia Tobacco QuitLine. Call 877-966-8784 for more information. You also may visit the West Virginia Tobacco QuitLine website.

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