Breast Health-Online Mammography Request

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION YOU SUBMIT THROUGH THE ONLINE MAMMOGRAM APPOINTMENT REQUEST AND PRE REGISTRATION FEATURE OF THIS WEB SITE MAY BE USED AND DISCLOSED. ALSO PLEASE REVIEW THE SAINT VINCENT HEALTH SYSTEM WEB SITE SECURITY POLICY AND THE NOTICE OF PRIVACY PRACTICES FOR MORE INFORMATION.

All information submitted in the online appointment and pre-registration form will be treated by Saint Vincent Health System as a confidential part of your medical record.

The information you submit on this form is made available to Saint Vincent Health System personnel for the purpose of scheduling your appointment and pre-registering you as a patient. By submitting this form, you are authorizing Saint Vincent Health System to contact your insurance company for verification of coverage and payment.

Upon arrival, you will need to complete the admission
process by:

1. providing copies of your insurance card(s) (Remember to bring your insurance card(s) with you each time you come for services; and
2. signing authorization forms.

Please note: This is a secured form that functions best using Internet Explorer 5.5 or higher. You may receive errors using other browsers.

Enter Online Appointment Request System