Physician Office Information Request Form - East Jefferson General Hospital

Please fill out the following information for your office. If you have any issues, please contact Christian Ellingsworth at (504) 503-7114 or csellingsworth@ejgh.org.
- Clinic Name*
- Supervisor Name*
- Address
  Street Address Address Line 2 City State ZIP Code
- Office Main Phone
- Office Fax
You may add up to FIVE USERS at a time using this online form. If you have more than five users, submit the first five and then refresh this page to add additional users. Please remember to click the SUBMIT button at the bottom of the page, or your request will not be sent.
USER 1:
- Name 1*
- Direct Phone 1
- Email 1*
- Billing or Office Staff 1
- Current MD Portal Account User 1
USER 2:
- Name 2
- Direct Phone 2
- Email 2
- Billing or Office Staff 2
- Current MD Portal Account User 2
USER 3:
- Name 3
- Direct Phone 3
- Email 3
- Billing or Office Staff 3
- Current MD Portal Account User 3
USER 4:
- Name 4
- Direct Phone 4
- Email 4
- Billing or Office Staff 4
- Current MD Portal Account User 4
USER 5:
- Name 5
- Direct Phone 5
- Email 5
- Billing or Office Staff 5
- Current MD Portal Account User 5