Physician Referral In order to process the appointment, please complete all of the information below. A referral coordinator will schedule an appointment and notify the clinic contact as quickly as possible. Please ensure the accuracy of the information provided.If you have already submitted initial patient information and only need to upload additional documents, CLICK HERE.Patient InformationPatient Name* First Middle Last Date of Birth* MM slash DD slash YYYY Sex* Female Male Not Specified Has the patient visited Jefferson Regional or any affiliated clinics before?* Yes No Unsure Primary Patient Phone Number*(Home or Cell)Alternate Patient Phone Number(Work Number)Patient Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician InformationThis information will be used by a referral coordinator to follow up on any additional needs before scheduling the appointment.Referring Physician Name Full Name Referring Physician PhoneReferring Physician NPI Clinic Contact Email Address Enter Email Confirm Email Clinic Contact Name* Full Name Clinic Contact PhoneSpecialty Clinic and Referral Physician SelectionSpecialty Requested* Please select Cardiology Endocrinology Gastro-Intestinal General Surgery Neurology OB/GYN Oncology Orthopedics Pulmonology Rheumatology Cardiology Associates of South Arkansas 1601 W. 40th Ave., Suite 301 Pine Bluff AR 71603 870-541-4285Cardiologist Ayman Alshami, MD Ricki Fram, MD Nicholas Willis, MD Janeil Shah, MD No preference Endocrinology of South Arkansas 7500 Dollarway Rd.., Suite 404 White Hall AR 71602 870-879-9595Endocrinologist Maher Alesali, MD No preference GI Associates of South Arkansas 1609 W. 40th Ave., Suite 202 Pine Bluff AR 71603 870-541-7201Gastro-Interologist Meer A. Ali, MD Ali Hussain, MD Ammar Ahmed, PA No preference Surgical Associates of South East Arkansas 1609 W. 40th Ave., Suite 403 Pine Bluff AR 71603 870-534-4188 1801 W. 40th Ave., Suite 7 Pine Bluff AR 71603 870-535-8280General Surgeon Michelle Eckert, MD Lee Forestiere, MD Heather LeBlanc, MD Charles Mabry, MD John Roland Taylor, MD Lee Morisy, MD John Roland Taylor, MD No preference JRMC Neurology Clinic 1601 W. 40th Ave., Suite 301B Pine Bluff AR 71603 870-541-8708Neurology Srilatha Thadur, MD No preference OB/GYN Associates of South Arkansas 1609 W. 40th Ave., Suite 301 Pine Bluff AR 71603 OB/GYN Reid Pierce, MD Kenneth J. Lambert, MD Amy Boast Cahill, MD Joe Browning, MD Katie Loetscher, APRN Megan Holloway, APRN Amanda Lem, APRN No preference Jefferson Regional Cancer Center 1609 W. 40th Ave., Suite 205 Pine Bluff AR 71603 870-541-3232Oncology Asif Masood, MD Abid Mohuiddin No preference South Arkansas Orthopaedics 1609 W. 40th Ave., Suite 501 Pine Bluff AR 71603 870-534-3449Orthopedic Surgeon Troy Birk, MD Roy Burrell, MD Alan Pollard, MD Jason Smith, MD (spine) Summer McGhee, APN No preference Pine Bluff Specialty Clinic 1601 W. 40th Ave., Suite 301 Pine Bluff AR 71603 870-541-4280Pulmonologist Nabeel Siddiqui, MD Khalid Mohammad, MD No preference Rheumatology Associates 4747 Dusty Lake Dr, Ste G1 Pine Bluff AR 71603 870-541-6015Rheumatologist No preference Reason for referral*File Upload Please upload a front/back copy of the patients insurance card, the most recent visit note, test results, x-rays, and/or reports that may be relevant to the visit. The files will be securely uploaded and directed to the specified specialty clinic.Secure File Upload (Please upload any appropriate documents here) Drop files here or Select files Accepted file types: pdf, doc, tif, jpg, Max. file size: 50 MB, Max. files: 10. A maximum of 10 files can be attached to the online referral. Please submit only .PDF, .JPG, .TIF, or .DOC files. The total file size should not be greater than 50MB. Jefferson Regional is committed to and has implemented many safeguards to ensure its devices, services, websites and data systems are compliant with the regulations and conditions set forth in the Health Insurance Portability and Availability Act of 1996 (HIPAA). PhoneThis field is for validation purposes and should be left unchanged.