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 to refer to QuitWorks. If you would like to explore the fully electronic process, please contact us.


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