Jackson Memorial Hospital

Thank you for your interest in medical services at the UM/Jackson Memorial Medical Center. We offer a comprehensive array of services for you to choose from. For your convenience, please fill out the following electronic inquiry form. As soon as the information is received, it will be assigned to a professional hospitality coordinator who will contact you within 48 hours.

Please indicate the urgency of your request by selecting one of the options based on the applicable status of your case.

Routine appointment
Appointments within 2 to 6 weeks

Rush appointment
Appointment within 1 week

Emergency Transfer
Request Hospital to Hospital

Full Name:
	First	Middle	Last
Email:
Gender:	Male Female
Birthday:		(ie. 01/01/2006)
Passport:

If US Citizen, please provide
SSN:
If Non-US Citizen
Country:
I have a visa to enter the USA		I need a visa to enter the USA

Best Contact Mode:
Preferred Language:		If other please indicate:
How did you hear about Jackson Memorial Hospital?:

Patient Primary Address
Address:
City:		State/Province:
Postal Code:		Country:
Home Phone:	(include country code if outside the US)
Cell Phone:	(include country code if outside the US)
Other Phone:	(include country code if outside the US)

	I am covered under the Medicare Program
If you are covered by Medicare Benefits, please complete the following:
Medicare beneficiary number:
State of Issuance:
Medicare Plus/Supplemental Insurance Company Name:
Group Number / Group ID:
Customer Service / Benefits Office Contact Number:
If you are covered by any other medical insurance that is not Medicare, please complete the following:
Name of Insurance Company:
Insurance Policy Number:
Group or Member ID Number:
Name of Policy Holder:
Customer Service Number:
Benefit Authorization Number:
Does your health insurance cover medical services at JMH?:	YesNoUnknown
If you would like to add any other information you believe would be helpful or leave a further message for the physician referral office, please type it here:

Information collected from this website, or provided on any form you have submitted through the website, will be used only in conjunction with an expressed interest by the User in obtaining additional information about medical services from the University of Miami Miller School of Medicine, University of Miami Medical Group, Jackson Memorial Hospital and other entities of the Jackson Health system. Information provided by User, does not create any type of relationship between the individual providing the information and Jackson Memorial Hospital, the Public Health Trust, the University of Miami Miller School of Medicine, the University of Miami Medical Group, Foundation Health Services Inc., or any of its physicians, staff, agents and directors, whatsoever. This information is not considered Protected Health Information (PHI) and will be used to contact you because you have requested to be contacted. In addition, information provided on the website, or in any response to you, is not and cannot be considered medical advice or treatment. The Jackson Memorial Hospital, the Public Health Trust, Foundation Health Services Inc., the University of Miami, or any of there entities, physicians, staff, agents and directors will not be liable for, and you will release and hold them harmless from, any claims and/or any direct, indirect, consequential, special, exemplary, or other damages arising therefrom, whatsoever. Please consult with your doctor for medical advice or treatment for any condition you may have.

If you are experiencing a medical emergency, call 911 and/or go to the nearest emergency room.

I have read, understood and agree to the above.