Medical Referral to the Jackson Free Clinic
Thank you for your patient referral to the Jackson Free Clinic. The JFC treats any individual above the age of 18 who is uninsured. Information entered into this form is protected by a HIPAA compliant Google Suite with the JFC. Please provide the information requested below and fax your patient's pertinent medical records (particularly relevant labs and imaging) to our clinic. Fax instructions are at the end of this form. 
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Email *
Referring provider's name and title *
Referring provider's organization *
Referring provider's contact information *
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