Multi-Page Information Form

Mobile Mammogram Registration

Early Detection Saves Lives
We know life gets busy, and it's easy to put your own health on the back burner. That's why MercyGate Church is partnering with MD Anderson Cancer Center to bring convenient mobile mammogram screenings right to our campus—making it easy to take an important step for your health in about 20 minutes.

As a special thank-you, everyone who completes a mammogram will be entered into our giveaway for a chance to win either a 4-pack of Nutcracker Market tickets & a Woodhouse Spa package!

Who is Eligible?

Women 40 years of age and older
Those due for a routine screening mammogram
No current breast concerns or symptoms
No personal history of breast cancer
Must have participating insurance

If you do not have insurance or are experiencing a current breast concern, please email Kellye@MercyGateChurch.com so we can help connect you with the appropriate resources and assist you directly.
Eligibility Requirements

Additional eligibility questions and insurance verification will be completed by MD Anderson when your appointment is confirmed. Insurance coverage must be verified and is subject to your individual insurance plan and benefits.
Eligibility Requirements
Appointment Request
Patients with breast augmentation require two consecutive (back-to-back) appointments to complete their mammogram.
Appointment Scheduling SCROLL TO FIND THE DATE & TIME YOU’D LIKE OCTOBER 5 & 6
Appointment requests are subject to availability. Your appointment is not confirmed until you are contacted by MD Anderson or the event coordinator.
Contact Information
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Who referred you to this Mammogram Outreach Event?
Acknowledgements

Please read and acknowledge the following:
Acknowledgements
PARTICIPANT ACKNOWLEDGMENT, AUTHORIZATION & FINANCIALRESPONSIBILITY I have read the Privacy Notice and authorize MercyGate Church to collect, use, and share the information I provide with MD Anderson for purposes of registration, insurance verification, scheduling, and coordination of my mammography screening. I understand that MD Anderson is solely responsible for providing the mammography screening and all related medical services, including clinical decisions, medical records, interpretation of results, follow-up recommendations, insurance claims, and billing. I understand that MercyGate Church is providing the event location and administrative/registration support only. MercyGate Church is not providing medical care or medical advice and is not responsible for the diagnosis, treatment, interpretation of screening results, follow-up care, insurance coverage, insurance claim processing, or billing associated with services provided by MD Anderson. I understand that I am financially responsible for any amounts charged by MD Anderson that are not paid by my insurance or another third party, including, as applicable, deductibles, copayments, coinsurance, non-covered services, out-of-network charges, denied claims, or other amounts for which I am responsible under my health plan. I understand that insurance coverage is determined by my individual health plan and that registration for or participation in this screening does not guarantee insurance coverage or payment. I am responsible for understanding my insurance benefits and, when appropriate, confirming coverage and network status with my insurance company and/or MD Anderson before receiving services. I understand that MercyGate Church does not make representations or warranties regarding whether my insurance will cover the screening or any related services, nor does MercyGate Church have authority over MD Anderson's charges, billing practices, insurance claims, coverage determinations, or collection of amounts owed. I agree that any questions or disputes regarding medical services, medical records, insurance claims, insurance coverage, charges, bills, or amounts owed for services provided by MD Andersonwill be directed to MD Anderson and/or my insurance provider, as applicable. By submitting this registration, I acknowledge that I have read and understand the above and agree to the terms of this acknowledgment.
Should be Empty:

Mobile Mammogram Registration

Eligibility Requirements

Appointment Request

Contact Information

Acknowledgements