Jefferson Regional Image Request *Providers Only*
jrimagereq@jrmc.org - 1600 W. 40th Ave I Pine Bluff, AR 71603 - 870-541-7470
X-Rays, Computerized Tomography (CT), MRI, Ultrasound, Nuclear Medicine, Breast Imaging/Mammography and PET CT
You will receive an invite to view images to the email provided on this form.
AUTHORIZATION FOR RELEASE OF MEDICAL IMAGES
From Facility to Facility - For Continuum of Care
Required Information:
Patient Name
*
First Name
Last Name
Patient Date of Birth:
*
-
Month
-
Day
Year
Date
Other Patient ID:
Patient SSN#
JR Med Record#:
This request is for the release of Medical Imaging Exams:
*
Computerized Tomography
X-Ray/Radiology Exams
Ultrasound
Nuclear Medicine
Breast Imaging (Mammography, Ultrasound and/or MRI)
PET CT
Please indicate date ranges:
Date
*
Date
*
Facility Contact Information
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
EMAIL MUST BE INCLUDED: You will receive a invite to view images to the email provided below:
*
example@example.com
Submit
Should be Empty: