Universal Enrollment Form
At the heart of the QuitWorks-RI program is a generic, universally endorsed enrollment form.
This universal form can be used by any provider with any patient, regardless of health insurance status.
Providers in office practices and in many health care facilities should download the universal enrollment form, add provider and practice contact information, and reproduce it for their use.
Universal Enrollment Form (Spanish) (PDF, 300 KB)
Customized Enrollment Forms for Hospitals, Health Centers and Public Health Programs
If you would like to customize QuitWorks-RI for your facility, please contact us.
NOTE: The enrollment forms are in PDF format. Adobe Acrobat Reader is required to view these forms and can be downloaded for free at www.adobe.com.