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Fax-To-Quit Louisiana

Fax-To-Quit Louisiana helps health care providers provide an easy and seamless counseling component to patients who are ready to quit tobacco. To become a certified Fax-To-Quit provider, simply complete the training module. The presentation takes about 15 minutes and will be followed by a short quiz.

Download the two PDFs to be discussed in the training module here:

Fax-to-Quit Referral Form Sample
Fax Back Form

Start the training session

Certified Health Care Provider Tool Kit
For participating in the program, you will receive a Fax-To-Quit Certified Health Care Provider Tool Kit featuring:

  • Fax-To-Quit Manual
  • Fax-to-Quit Referral Form
  • Office Guide
  • Medicaid Brochure
  • Quit Referral Cards

If you experience any technical difficulties, please contact Hillary Sutton at


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Fax-to-Quit Louisiana Program
  • 1-800-QUIT-NOW (1-800-784-8669)
  • Cessation services for individuals who want to quit tobacco use
  • Free
  • Louisiana residents age 13 years and older
  • Available in English, Spanish and over 170 different languages through translation services
  • Hearing impaired and deaf services available – 1-877-777-6534
Services Through 1-800-QUIT-Now
  • Proactive Counseling Sessions with a trained Quit Coach’”¢
    • Counselors call the tobacco user at set appointment times
    • Counsel them through the quitting process and relapse phase
  • Self-help guides to help tobacco users cope with withdrawal and craving symptoms between phone sessions and increase chances of permanent tobacco cessation.
Additional Quitline Services
  • Information on local programs

** Freedom From Smoking Clinics – Works in conjunction with the American Lung Association

** Tobacco Control Initiative – Works in conjunction with LSU Charity Hospital System

Louisiana Tobacco Quitline



Quitlines Are Effective

CDC 12-month Follow-up Study, 32 qualifying studies

  • 41% improvement in quit rates (positive median difference of 2.6 points)
  • Compared to smokers who did not receive telephone counseling
Fax-to-Quit Louisiana Program Connects the Quiter with the Quitline
  • Referral from healthcare provider
  • Proactive calls from the Quitline QuitCoach’”¢
Who Should be Referred to the Quitline
  • Must be serious about quitting in 30 days
  • Agree to a set quit-date in 30 days with the quit coach
  • Willing to receive calls from the quitline
  • Have reliable access to a phone
Who Should Not Be Referred to the Quitline
  • Hesitant about quitting
  • Irregular access to phone
  • Not enthusiastic about receiving calls on cell phone or at home
Fax-To-Quit Interventions

5 A’s – Ask, Advise, Assess, Assist, Arrange

Three Step Referral Process for the clinical setting

  • Ask: your patient about their smoking status
  • Advise: your patient to quit as soon as possible
  • Refer: Quitline

Only those ready to quit in 30 days and willing to receive calls should be referred.

Incorporating Fax-To-Quit Louisiana into your practice
  • Designate one or more staff members to implement
  • Ask about tobacco use
  • Advise patients who use tobacco to quit
  • Fill out a consent for for patients who are interested in phone counseling and fax
  • If a patient is not interested in phone counseling, suggest group counseling or other options
  • Provide quitline card or brochure to patients not yet ready to quit
Download the Sample Fax Referral Form

Download PDF

Patient Progress Report

If you haven’t downloaded the Fax Referral form, please do so now.

Smoking Cessation Medications
  • Pharmocotherapies can help individuals quit tobacco use
  • Research shows pharmocotherapies reliably increase long-term smoking abstinence rates
  • Seven FDA-approved medications include: nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine patch, and nicotine lozenges. Bupropion SR (Zyban or Wellbutrin), Varencline (Chantix).
Medicare Coverage

Any Medicare beneficiary [Part A or B] who smokes will now be able to receive counseling

Medicare will cover 2 tobacco cessation attempts per year. Each cessation attempt equals 4 counseling sessions. This totals to 8 sessions per year for one patient.

Medicare Prescription Drug Program [Part D] covers smoking cessation medication

Medicare: Cessation Counseling Session Defined
  • Defined as face-to-face patient contact
  • CPT 99406: tobacco cessation counseling visit, intermediate, greater than 3 minutes and up to 10 minutes
  • CPT 999407: tobacco cessation counseling visit, intensive, greater than 10 minutes
Medicaid covers six smoking cessation medications
  • Nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine patch, Bupropion SR (Zyban or Wellbutrin), Varenicline (Chantix)
  • Requires all prescriptions to be hand-written and signed by the doctor
  • Prescription must indicate “recipient is enrolled in a physician-supervised behavioral program”
  • Prewritten and prefilled out prescription pads will not be accepted
Tobacco-Use Diagnostic Codes (ICD-9-CM)
  • 305.1: cases in which tobacco is used to the detriment of a person’s health or social functioning or in which there is a tobacco dependence
  • V15.82: cases in which your patient shows a history of tobacco use
Please complete the questionnaire

Please complete the questionnaire to finalize your training

Thank You

How often should you ask about or otherwise identify a patient's smoking status at a typical visit (including new patient, problem, and health maintenance visits)?
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What is the purpose of the Fax-To-Quit Louisiana Program?
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If I advise a patient to quit smoking or using tobacco products and they choose not to be referred to the Quitline, I should?
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Congratulations! You passed.

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Share Your Quit Story

Everyone's quit story is different. What works for one, might not always work for another. So we want you to share your success story (and your struggles) with us, so that you can help motivate and encourage others to quit.

Please tell us your story...