QuitWorks: a solution for providers to help patients quit smoking.
Massachusetts Department of Public Health

Customized Referral Forms

The heart of the QuitWorks program is the referral process.  Any patients, regardless of insurance status, can be referred to QuitWorks.

Universal Referral Forms
Customized Paper Referral Forms
Electronic Referrals
Find a Customized Paper Referral Form

Universal Referral Forms

For providers and facilities without a customized form, download the universal form to begin using QuitQWorks today.

Customized Paper Referral Forms

Many large providers in Massachusetts—health centers, clinics, and hospitals—use a customized QuitWorks referral form.  These forms help large practices, health centers, and hospitals improve workflow and measure results.  QuitWorks can:

  • Add a facility or practice name and logo to the form to help QuitWorks identify the referring location.
  • Pre-populate any portion of the Healthcare Provider’s section at the bottom of the form to help reduce the amount of time it takes to complete a referral.
  • Create a form that does not require a patient signature for healthcare providers who contact patients by phone.
  • If you would like to customize QuitWorks for your facility or explore the fully electronic process, please contact us.

Electronic Referrals

Some facilities have adopted an electronic referral process. If your facility name is listed below contact your administrator to learn how to refer to QuitWorks

  • Atrius/HVMA

  • Dorchester House Multi-Service Center

  • Codman Square Community Health Center

  • MIT Medical

  • Tufts Medical Center

Find a Customized Paper Referral Form

Hospitals
Anna Jaques Hospital
Brigham & Women's Hospital
Boston Children's Hospital
Franklin Medical Center
Harrington Hospital
Holyoke Medical Center
Lawrence General Hospital
Lawrence General Hospital - Spanish
Lowell General Hospital
Marlborough Hospital
Marlborough Hospital - Spanish
Massachusetts General Hospital
MetroWest Medical Center
North Shore Medical Center
Southcoast Hospitals Group

Sturdy Memorial Hospital
Sturdy Memorial Hospital - Spanish
UMass Health Alliance
UMass Memorial Medical Center
UMass Memorial Medical Center - Spanish

Health Centers
Chicopee Health Center
The Community Health Center of Franklin County
The Community Health Center of Franklin County - Spanish
Dimock Center
East Boston Neighborhood Health Center
East Boston Neighborhood Health Center - Spanish
Great Brook Valley Health Center
Greater New Bedford Community Health Center
Joseph M. Smith Community Health Center
Lowell Community Health Center
Manet Community Health Center
Mattapan Community Health Center

Public Health Programs
EIPP
Home Health VNA
Massachusetts Rehabilitation Commission (MRC)

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