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 SPARROW HEALTH SYSTEM WEB SITE SECURITY POLICY AND THE SPARROW HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES FOR MORE INFORMATION.

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

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

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

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