JHS | Patient Appointment Request

Jackson Health System - Patient Appointment Request

For urgent matters, please call 305-585-4564.
The referring physician's office will begin to process this request by the next business day.

Thank you for the opportunity to help care for your patients.

Referring Healthcare Organization Master Account

Practice or Organization

Contact Number

Email

Referral Information

Provider Information

Referring Provider Full Name

NPI

Contact Number (if other than in Organization Master Account)

PCP (If other than referring provider)

Referral Coordinator

Referral Coordinator's Email

If organization has multiple clinics, please specify location

Patient Information

First Name

Last Name

Date of Birth

Preferred Language

Contact Number

Email Address

Insurance Carrier

Insurance Membership Number

Preferred Method for Appointment Scheduling

Patient's Preferred Days & Times

Patient Diagnosis

Service Information

Facility

Service

Preferred Jackson Physician

Is This a STAT Request?

Medical records, referrals, and authorizations can be uploaded through this site or faxed to 305-355-1560.

Please upload supporting documents such as patient insurance card, referral and medical records.
You can take a picture with your phone or upload your previously scanned documents.

Upload Documents

Uploaded Documents

Reset

Submit

Jackson Health System - Patient Appointment Request

For urgent matters, please call 305-585-4564.

The referring physician's office will begin to process this request by the next business day.

Thank you for the opportunity to help care for your patients.

Medical records, referrals, and authorizations can be uploaded through this site or faxed to 305-355-1560.