State Selection

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To refer a youth 13-17 years of age please contact Paola Klein at paola-klein@ouhsc.edu
We are sorry, your state isn't currently part of the My Life My Quit program. Please contact your local Department of Health for additional resources.
Thank you, unfortunately we are not able to move forward with your enrollment process. Please contact your school or local health department to complete the QuitLine Waiver process.
Patient Information
To be referred to the My Life My Quit program you must be under 18 years old. If you are over 18 years old please call 1-800-Quit Now (1-800-784-8669) to speak with a QuitLine representative.
The patient has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, medication shipment, and quit anniversaries. The patient has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, and quit anniversaries.
Standard message and data rates may apply. The patient may opt-out at any time. Provider, please verify the youth patient is able to receive messages on the provided phone number.
Is it ok to leave a voicemail?
Is patient hearing impaired?
If a specific Medicaid insurance is not selected, we will not be able to connect the patient with additional Medicaid cessation benefits. Please select a specific Medicaid insurance if possible.
Clinic Information

Authorization

*Patient gives permission to the Nebraska Tobacco Quitline to share information with their provider for the purposes of their health care treatment.
We can not submit the referral unless the patient consents to be referred to the Quitline.
*Patient gives permission to the Nebraska Tobacco Quitline to share information with their Heritage Health providers for the purposes of their health care treatment.
We will not be able to connect the patient with additional Medicaid cessation benefits.