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Nicotene Replacement Request

Nicotine Replacement Therapy (NRT) Request

Nicotine replacement therapy (NRT) is a proven method to help people quit smoking by providing a controlled dose of nicotine without the harmful chemicals found in tobacco products. Available in various forms—such as patches, gum, lozenges, nasal spray, and inhalers—NRT works by reducing withdrawal symptoms and cravings, making it easier for individuals to gradually wean themselves off nicotine. These products should always be used as directed by the manufacturer to ensure safety and effectiveness. When combined with behavioral support, NRT can significantly increase the chances of successfully quitting smoking and improving overall health.

1. Date This question requires a valid date format of MM/DD/YYYY.

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Which county do you live in? *This question is required.

Your first and last name *This question is required.

Your date of birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Your address *This question is required.

Street
City
State
Zip Code

Your phone number *This question is required.

Please include the area code to your phone number. You may enter it with the parentheses (###) ###-### or ###-###-####.

Do you have health insurance? *This question is required.

Do you have Medicaid or an MCO (Managed Care Organization) healthcare coverage? Such as Ky Medicaid, Aetna Better Health of Kentucky, Humana Healthy Horizons of Kentucky, Passport Health Plan by Molina Healthcare, United Healthcare Community Plan, or Wellcare of Kentucky? *This question is required.

Please select the type of Medicaid or MCO coverage that you have.

Medicaid	Aetna Better Health of KY	Humana Healthy Horizons of KY	Passport Healthplan by Molina Healthcare	United Healthcare Community Plan	Wellcare of KY
Medicaid	Aetna Better Health of KY	Humana Healthy Horizons of KY	Passport Healthplan by Molina Healthcare	United Healthcare Community Plan	Wellcare of KY

Are you pregnant or nursing?

Do you consent to allow Three Rivers to bill your Medicaid/MCO for the NRT services to be provided? *This question is required.

Please provide your Medicaid/MCO member ID. *This question is required.

Which type of NRT are you requesting? *This question is required.

Patches
Gum
Lozenges
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

How would you like to receive your NRT? *This question is required.

Have you tried another form of cessation before? *This question is required.

Have you called the QuitLine? (1-800-QUIT-NOW 7848-669)

*This question is required.