Physician Network Referral Form
IF THIS IS AN URGENT REQUEST PLEASE COMPLETE AND SUBMIT THE FORM BELOW, AND CALL THE CLINIC DIRECTLY TO SCHEDULE THE APPOINTMENT
REFERRING DOCTOR INFORMATION
Referring Provider Name
Referring Provider Phone Number
Referring Provider Fax Number
Referring Provider Office Contact Person
Please enter name and phone number of person that can be contacted for any questions
Street Address Line 2
City
State / Province
Postal / Zip Code
PATIENT INFORMATION
Patient Name
First
Last
Date of Birth
-
Month
-
Day
Year
Contact Number
Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Insurance
Primary Insurance ID Number
Primary Insurance Group Number
Primary Insurance Subscriber
Secondary Insurance
Secondary Insurance ID Number
Secondary Insurance Group Number
Secondary Insurance Subscriber
Reason for Referral
*
Referral Requested For
*
Please Select
Jefferson Regional Cardiology Clinic
Jefferson Regional Ear, Nose, & Throat Clinic
Jefferson Regional Endocrinology Clinic
Jefferson Regional Gastrointestinal Clinic
Jefferson Regional General Surgery Clinic
Jones-Dunklin Cancer Center
Jones Dunklin Radiation Center
Jefferson Regional Nephrology Clinic
Jefferson Regional OB/GYN Clinic
Jefferson Regional Orthopedic Clinic
Jefferson Regional Pulmonology Clinic
Jefferson Regional Rheumatology Clinic
Jefferson Regional Urology Clinic
Jefferson Regional Wound Care
Jefferson Regional Cardiology Clinic Referral Requirements
Please note: Our providers do not treat patients under the age of 18. Referrals for individuals under the age of 18 will not be accepted
Jefferson Regional Cardiology Clinic Appointment Locations- Please select
Pine Bluff
Dumas
Monticello
Select Cardiology Provider
First Available Physician
Ricki Fram, MD
Jainil Shah, MD
Mauro Taveras, MD
Nicholas Willis, MD
Cardiology Provider
Ricki Fram, MD
Cardiology Provider
First Available
Jainil Shah, MD
Nicholas Willis, MD
Mauro Taveras, MD
Select Ear Nose and Throat Provider
Christine Mirabal, MD
Select Endocrinology Provider
Maher Alesali, MD
Select Gastroenterology Provider
Ian Gaillard, MD
Jones Dunklin Cancer Center Appointment Locations- Please select
Pine Bluff
Monticello
Select Jones Dunklin Cancer Center Provider
First Available Physician
Brian Jimenez Campbell, MD
Asif Masood, MD
Jones Dunklin Cancer Center Provider
Brian Jimenez Campbell, MD
Select Jones Dunklin Radiation Center Provider
Shahid Hameed, MD
Select Nephrology Provider
First Available Physician
James Campbell, MD
Syed Shah, MD
Brandi Wright, MD
Select OB/GYN Provider
First Available Physician
Amy Cahill, MD
Kenneth Lambert, MD
Reid Pierce, MD
Megan Holloway, APRN
Jefferson Regional Orthopedic Clinic Appointment Locations- Please select
Pine Bluff
Monticello
Select Orthopedic Provider
First Available Physician
Troy Birk, MD
Roy Burrell, MD
Alan Pollard, MD
Select Orthopedic Provider
First Available Physician
Troy Birk, MD
Roy Burrell, MD
Jefferson Regional Pulmonary Clinic Referral Requirements-Please note: Our providers do not treat patients under the age of 18. Referrals for individuals under the age of 18 will not be accepted
Pulmonary Function Testing (PFT) is required prior to clinic visit unless, the referral is for an abnormal chest x-ray or chest CT scan, including suspicious nodules. If a PFT has not been done prior to referral, our office will coordinate scheduling the PFT appointment prior to the clinic visit. If referral is for abnormal chest x-ray or chest CT scan, please make sure our office has a copy of the study and the report prior to requesting the referral
Select Pulmonology Provider
First Available Physician
Sarenthia Epps, MD
Rachel Idowu, MD
Nabeel Siddiqui, MD
Select Rheumatology Provider
First Available Physician
Maaman Bashir, MD
Snigdha Gadireddy, MD
Rheumatology Referral Requirements- We do not treat previously diagnosed Fibromyalgia or Chronic Pain Syndrome unless there is concern for an autoimmune or rheumatological disease process. We do not treat patients under the age of 18.
Abnormal Labs (ANA, CRP, RF, ESR, CCP, Uric Acid (Please check below)
Abnormal Pathology
Abnormal Imaging (Please check below)
Other
Select Abnormal Labs
ANA
CCP
RF
ESR
CRP
Uric Acid
Other
Select Abnormal Imaging
X-Ray
MRI
CT
Other
Jefferson Regional General Surgery Clinic Appointment Locations- Please select
Pine Bluff
Dumas
Select General Surgery Provider
First Available Physician
Roger Alan Blake, MD
Michelle Eckert, MD
Lee Forestiere, MD
Heather LeBlanc, MD
Madison Lim, MD
Charles Mabry, MD
Irfan Qureshi, MD
Leigh Anna Robinson, MD
JR Taylor, MD
Select General Surgery Provider
First Available Physician
Michelle Eckert, MD
Madison Lim, MD
Jefferson Regional Urology Clinic Appointment Locations- Please select
Pine Bluff
Stuttgart
Monticello
Warren
Sheridan
Select Urology Provider
First Available Physician
Jordan Hanberry, MD
Nathan Green, MD
Nick Scherzer, MD
Urology Provider
Nathan Green, MD
Urology Provider
Jordan Hanberry, MD
Urology Provider
Nick Scherzer, MD
Urology Provider
Nick Scherzer, MD
Select Wound Care Provider
Kelly Wright, APRN
Is patient diabetic?
Yes
No
Is wound open and/or draining?
Yes
No
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Cardiology Fax: (870)541-4290
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Ear, Nose & Throat Fax: (870)541-6056
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Endocrinology Fax: (870)879-9599
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Gastroenterology Fax: (870)541-7202
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional General Surgery Fax: (870)541-6071
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jones Dunklin Cancer Center Fax: (870)541-3231
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jones Dunklin Radiation Oncology Fax: (870)541-3241
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Nephrology Fax: (870)541-6021
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional OB/GYN Fax: (870)541-6046
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Orthopedics Fax: (870)535-3973
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Pulmonology Fax: (870)541-4282
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Rheumatology Fax: (870)541-6016
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Urology Fax: (870)541-6061
Please upload or fax the most recent clinic note, operative/procedure notes and any pertinent lab, x-ray, diagnostic testing results. For diagnostic testing, please send a copy of the disk to our office or have the patient bring with them to their appointment
Jefferson Regional Wound Care Fax: (870)541-8748
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