Provider Web Referral

Provider Web Referral

For Patients Without NRT Contra-indications
Complete the Provider Web Referral. You don’t need to print any pages.
eReferral

eReferral

For Providers Interested in using eReferral
Please submit our Contact Us form to learn more about our eReferral program.

Authorization To Disclose Health Information

If a participant has any of the following contraindications to using NRT and you would like them to receive NRT we recommend you to print, sign and fax in the Fax Referral form as well as the Authorization to Disclose Health Information form. Contraindications: heart disease or conditions, uncontrolled high blood pressure, stroke or heart attack in the last 12 months, pregnant or breast feeding.

Fax referral

For Patients With NRT Contra-indications
If a patient has contra-indications to using NRT, please print, sign and return a Fax Referral form.