Quitline QuitlinePlease enable JavaScript in your browser to complete this form.Provider Information: ASPIN - Navigators 8440 Woodfield Crossing Blvd. Suite 460 Indianapolis, IN 46240 I am HIPAA-Covered Entity: NO Phone: 317.471.0000 Fax: 317.735.0019Date: Gender:MaleFemalePregnant?YesNoPatient Name: *Date of Birth: *Address: *City: *State: *Zip Code: *County: *Fax:Email:Primary Phone: *The above is what type of phone?HomeWorkCellOtherSecondary Phone:The above is what type of phone?HomeWorkCellOtherLanguage Preference (check one): *English SpanishOtherTobacco Type (check all that apply): *CigarettesSmokeless TobaccoCigarPipeI am ready to quit tobacco and request the Indiana Tobacco Quitline contact me to help me with my quit plan. *YesNoI do not give my permission to the Indiana Tobacco Quitline to leave a message when contacting me.YesNoThe Indiana Tobacco Quitline will call you. Please check the BEST 3-hour time frame for them to reach you. Note: The Quitline is open 7 days a week; call attempts over a weekend may be made at times other than the selected 3-hour time frame. Best Time? *6am-9am9am-12pm12pm-3pm3pm-6pm6pm-9pmSubmitted by (Three (3) initials):WebsiteSubmit
