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State Selection

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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.
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.
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.
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.
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.
Does the patient require accommodation while participating in the program such as TTY, translator, or relay service?
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.
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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.