Foundation Hospitality Services

Thank you for your interest in medical services at the University of Miami/Jackson Memorial Medical Center. Our medical center offers 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.

Thank you for trusting the University of Miami/Jackson Memorial Medical Center with your health care needs.

* Required field

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

Routine Request
Appointments within
2 to 6 weeks

Rush Request
Appointment within
1 week

Emergency Transfer Request
Hospital to hospital

Patient Information

* Full Name:


First	Middle	Last

* Gender:

Male Female

If International

Country:
Passport Number:
I have a visa to enter the USA
I need a visa to enter the USA

* Birthdate:

(ie. 01/01/2006)

Are you 18 years or older Yes No

* Address:


City:
State/Province:		Postal Code/Zip:
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)

* Email:

* Best Contact Mode:

* Preferred Language: if other please indicate

* How did you hear about Jackson Memorial Hospital?

Medical Information

* Clinical Diagnosis/Reason for Requested Service:

* Service Needed:

Select from the list of services

Type in service required if not listed:

* When did your symptoms began?

* Please describe your treatment to date and your doctor's recommended course of treatment for managing your medical situation.:

You may also fax a hard copy of your medical documents to 305-355-5545.
Please include a cover sheet with your contact information and number all pages of your fax transmission.

Documents must be provided in English and signed by your treating physician.

Blood Type:

ALLERGIES:
List all your allergies

MEDICAL STATUS:
List all existing (active) medical conditions (eg: if diabetic, list insulin intake. If hypertensive, list your "normal" blood pressure. List all medications by name and dosage.

MEDICAL HISTORY:
List previous operations, procedures, conditions for which you were treated.

Referring Physician Information

Physician Name:

Physician Specialty:

Physician Email:

Physician Telephone Number:

(include country code if outside the US)

Physician Cell Number:

(include country code if outside the US)

Address:


City:
State/Providence:		Postal Code/Zip:
Country:

Insurance Information
You will be contacted in order to review insurance coverage and obtain additional demographic information. Medical and financial eligibility will need to be established prior to confirming an appointment. To expedite this verification, you may provide us with the following optional information.
I am covered under the Medicare Program Yes No
If you are covered by Medicare Benefits, please complete the following:
Please provide your 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:	(include country code if outside the US)
Benefit Authorization Number:	(include country code if outside the US)
Does your health insurance cover medical services at JMH?	Yes No Unknown
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.

Requests for information, and or requests for appointments, will be answered within two business days by telephone or e-mail. JMH-International is open Monday through Friday from 8:30 a.m. to 5:30 p.m. Eastern Standard Time, USA. JMH-International maintains 24/7 on call service for medical emergencies that require a transfer of critically ill, or critically injured patients to our hospital. You may call us directly during business hours at 305-355-5544. After hours on call service number 786-367-4914. (Back up number: 305-585-5354)

BUPA International Patient Hospitality Center
Jackson Memorial Hospital, North Entrance
DTC Building, Ground Floor
1080 N.W. 19th Street
Miami, FL 33136 | hospitality@jmhi.org

Administrative and mailing address
Jackson Memorial Hospital International Services
Jackson Medical Towers, East Tower
1500 N.W. 12th Avenue, Suite 829
Miami, Florida 33136-9998