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Free Planned Parenthood Proof Template

The Planned Parenthood Proof form is a document designed to collect essential information from patients seeking medical services, specifically related to pregnancy testing. This form ensures that individuals understand their rights and responsibilities while maintaining confidentiality throughout the process. By filling out this form, patients can communicate their medical history, preferences, and any concerns they may have regarding their care.

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The Planned Parenthood Proof form is an important document designed to facilitate medical services and ensure that patients receive the care they need in a respectful and confidential manner. This form collects essential information about the patient, including personal details like name, address, and contact information, as well as medical history relevant to the services requested. Patients are asked to indicate their reason for seeking a pregnancy test, whether due to a planned pregnancy or a contraceptive failure, among other options. Additionally, the form emphasizes the importance of communication by allowing patients to specify how they prefer to be contacted regarding their test results, ensuring their privacy is maintained. It also includes sections for medical screening, where patients can disclose any symptoms they may be experiencing, and provides an opportunity to discuss sensitive topics like birth control and past experiences with partners. Finally, the form outlines the patient’s rights, including the right to ask questions and the assurance of confidentiality in accordance with health information privacy practices. Overall, the Planned Parenthood Proof form serves as a vital tool in the patient care process, promoting transparency and informed consent throughout the medical experience.

Key takeaways

Filling out the Planned Parenthood Proof form is an important step in accessing healthcare services. Here are key takeaways to keep in mind:

Print Clearly: Ensure all information is legible to avoid delays in processing.
Contact Methods: Indicate how you prefer to be contacted regarding test results—phone or mail.
Confidentiality: Your privacy is a priority. Information will be shared discreetly.
Emergency Contact: Provide a reliable emergency contact name and phone number.
Medical History: Be honest about your medical history and any symptoms you may be experiencing.
Income Information: Include your monthly income and family size, as this may affect service options.
Education Level: Indicate your highest level of education completed; this helps in providing appropriate information.
Test Purpose: Clearly state the reason for the pregnancy test, such as planned pregnancy or contraceptive failure.
Ask Questions: If anything is unclear, don’t hesitate to ask staff for clarification.
Consent: Understand that signing the form means you consent to the services and understand your rights.

By following these guidelines, you can ensure a smoother experience when using the Planned Parenthood Proof form.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it's essential to ensure accuracy and clarity. Here are some important dos and don'ts to consider:

Do print your information clearly and legibly to avoid any misunderstandings.
Do provide accurate contact information, including phone numbers and email addresses, to ensure you can receive important updates.
Do check the appropriate boxes regarding your medical history and reasons for the test; this helps the staff provide the best care.
Do ask questions if anything is unclear; understanding the form is crucial for your health care.

Don't leave any sections blank unless instructed; incomplete forms can delay your care.
Don't provide false information; honesty is vital for your safety and treatment.
Don't forget to sign and date the form; your consent is necessary for processing.
Don't hesitate to request assistance if you need help understanding any part of the form.

Documents used along the form

When seeking services from Planned Parenthood, there are several important documents that may accompany the Planned Parenthood Proof form. Each of these forms serves a unique purpose, helping to ensure that patients receive the appropriate care while maintaining their rights and privacy. Here’s a brief overview of these related documents.

Patient’s Bill of Rights and Responsibilities: This document outlines the rights and responsibilities of patients receiving care. It emphasizes the importance of informed consent, confidentiality, and respectful treatment. Understanding these rights helps patients feel empowered during their healthcare journey.
Request for Medical Services: This form is essential for patients to formally request medical services. It includes sections for patients to provide personal information, describe their medical needs, and consent to treatment. This ensures that the clinic has the necessary information to provide appropriate care.
Asurion F-017-08 MEN Form: This crucial document is used for processing specific insurance claims related to electronic devices, ensuring customers receive the support they need in a timely manner. To access the form, visit pdftemplates.info.
Acknowledgment of Receipt of Notice of Health Information Privacy Practices: This document informs patients about how their health information will be used and protected. By signing this acknowledgment, patients confirm that they understand their rights regarding privacy and the handling of their medical information.
Consent for Treatment: Patients are often required to sign a consent form before receiving any medical services. This form ensures that patients are fully informed about the procedures they will undergo, including any risks and benefits associated with their treatment options.
Insurance Information Form: For those with health insurance, this form collects necessary details about the patient’s insurance coverage. Providing this information helps streamline the billing process and ensures that patients receive the benefits they are entitled to.

Each of these documents plays a crucial role in the healthcare process at Planned Parenthood. They not only facilitate communication between patients and healthcare providers but also safeguard patients' rights and privacy. Understanding these forms can help individuals navigate their healthcare experience more confidently.

⇓ PDF Form

Things to Know About This Form

What is the Planned Parenthood Proof form?

The Planned Parenthood Proof form is a document used by Planned Parenthood of Southeastern Virginia to collect essential information from patients seeking medical services, including urine pregnancy tests. It ensures that the clinic has accurate data to provide appropriate care while maintaining patient confidentiality.

How do I fill out the form?

Please print legibly and provide all requested information. This includes your name, contact details, and medical history. Make sure to answer questions about your last menstrual period, any current symptoms, and your contraceptive use. If you have any questions while filling out the form, do not hesitate to ask clinic staff for assistance.

Why do I need to provide my income and family size?

Providing your income and family size helps the clinic determine eligibility for various programs and services. This information is crucial for assessing your needs and ensuring you receive appropriate care and support.

What if I have a living will?

If you have a living will, please indicate this on the form. This information is important for the clinic to understand your healthcare preferences and ensure they are respected during your treatment.

How will my information be kept confidential?

Planned Parenthood is committed to maintaining your confidentiality. Your information will be stored securely and shared only with authorized personnel involved in your care. Communication about your test results will be conducted through secure methods, such as phone calls or mail, using plain envelopes to protect your privacy.

What should I do if I have questions about the form?

If you have any questions or need clarification about the form, please ask the clinic staff. They are available to help you understand the information and ensure you feel comfortable completing the form.

Can I change my mind about receiving services?

Yes, you have the right to change your mind at any time regarding the medical services you wish to receive. Your consent is voluntary, and you can withdraw it whenever you feel it is necessary.

What happens if I test positive for a sexually transmitted infection?

If you test positive for certain sexually transmitted infections, the clinic is required by law to report these results to public health agencies. You will also receive referrals for further diagnosis or treatment, if necessary, and the clinic staff will guide you through the next steps.

How can I contact Planned Parenthood if I have further questions?

You can reach Planned Parenthood of Southeastern Virginia at their Hampton office at (757) 826-2079 or at their Virginia Beach location at (757) 499-7526. They are ready to assist you with any questions or concerns you may have.

Preview - Planned Parenthood Proof Form

PLANNED PARENTHOOD® OF SOUTHEASTERN VIRGINIA

403 Yale Drive, Hampton, VA 23666 (757)826-2079

515 Newtown Road, Virginia Beach, VA 23462 (757)499-7526

PLEASE PRINT LEGIBLY

URINE PREGNANCY TEST

 (PLEASE CHECK) I have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy

Last Name:

First Name:

Middle Initial:

Address:

Apt #

City:

State:

Zip Code:

Employer:

Email address: (cannot be used for test results)

Home Phone #:

Cell Phone #:

Work Phone #:

Emergency Contact Name:

Phone Number:

We are committed to maintaining your confidentiality. At times it is necessary for us to contact you, usually with the

results of an abnormal test, through phone calls, email, text &/or mail (plain white envelope)

Please check the methods we can use to contact you? Phone Call

Mail

Please provide a password to receive test results over the phone____________________

Date of Birth

Sex  Female

 Transgender

Monthly Income

Family Size Supported By

Pronoun you like:  She  Other ____

Income

Do you have a living will?

 Yes

No

How did you hear about us?  AD (circle)

Billboard

Phonebook

Radio

Newspaper/Magazine

 Other Planned Parenthood

 Doctor

Family

Friends

School

Online

Facebook

Race

 Caucasian

 American Indian/Alaskan

Multiracial

Ethnicity

 African American

 Asian

 Pacific Islander

Other

Hispanic? Yes  No

Highest Level Of Education Completed  Middle School

 High School Some College

Bachelors/Masters/PhD

MEDICAL SCREENING (COMPLETED BY CLIENT)

1st day of last menstrual period __________

Was it normal?  Yes  No If no, explain:______________________

Reason for Test

 Planned Pregnancy  Contraceptive Failure  No Regular Birth Control

Test Results You Hope To See

 Negative

 Positive

 Doesn’t matter

Yes

Are you currently experiencing?

Yes

Are you currently using birth control?

Spotting/Bleeding

Fever

If yes, what method? ___________________

Abdominal Pain

For how long?

Vomiting

Do you have a history of?

Yes

Abnormal Bleeding

Would you like to discuss problems related to a

Ectopic Pregnancy

rape or emotional/physical/sexual abuse?

Missed or Spontaneous Abortion (Miscarriage)

Has your partner ever messed with your birth control or tried to

Pelvic Infection

get you pregnant when you didn’t want to be?

Are you currently experiencing any signs or

Does your partner refuse to use a condom when you ask?

symptoms of pregnancy?

Has your partner ever tried to force or pressure you to become

If yes, explain:

pregnant when you didn’t want to be?

Are you afraid of your partner?

ASSESSMENT (COMPLETED BY CLINIC STAFF)

Gravida

Para

Live Births

Spontaneous Abortion __ __ Elective Abortion_ ___ Living children _ __

Urine high-sensitivity HCG Pregnancy Test Order/Result:  Negative Positive (EDC:_______EDD:________)  Indefinite

Patient Education				V	H		V	H	For NEGATIVE Results-
V=Verbal H=Handout			CIIC EC			CIIC Pregnancy Tests			 Explained limitations of test (morning urine
	V	H	CIIC HOPE			STIs			sample/time since last period)
	V	H	CIIC HOPE			STIs			 Advised re-test in 1-2 weeks
BCM Options			CIIC Contraceptive Implant			Prenatal Care			 Advised re-test in 1-2 weeks
BCM Options			CIIC Contraceptive Implant			Prenatal Care			 Discussed blood PT
CIIC Pill,Patch, Ring			CIIC IUC			Adoption			 Discussed blood PT
CIIC Pill,Patch, Ring			CIIC IUC			Adoption			 Advised RTO if no menses for 3 consecutive
CIIC DMPA			CIIC Barriers (condoms)			Abortion			months
CIIC POPs			CIIC Essure			CI Sx of Early Pregnancy			If Minor: Encouraged parental involvement
Intake Staff Signature:						Date:
Licensed Qualified Staff Signature:						Date:

Revised March 2014

Request for Medical Services and Acknowledgement of Receipt of Notice of Health Information Privacy Practices I-B-2a Revised June 2012

PLANNED PARENTHOOD® OF SOUTHEASTERN VIRGINIA

403 Yale Drive, Hampton, VA 23666 (757)826-2079

515 Newtown Road, Virginia Beach, VA 23462 (757)499-7526

REQUEST FOR MEDICAL SERVICES AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

DATE _______________________________

PATIENT LABEL

Before you give your consent, be sure you understand the information given below. If you have any questions, we will be happy to talk about them with you. You may ask for a copy of this form.

I understand that I must tell the staff if language interpreter services are necessary to my understanding of the written or spoken information given during my health care visits. I understand that free interpretive services may not be immediately available and Planned Parenthood may need to refer me to another health care facility to provide the services necessary for my care.

I understand that the information I will provide is true, accurate, and complete and that my healthcare choices will depend on that information.

I will be given information about the test(s), treatment(s), procedure(s), and contraceptive method(s) to be provided, including the benefits, risks, possible problems/complications, and alternate choices. I understand that I should ask questions about anything I do not understand. I understand that a clinician is available to answer any questions I may have.

Please note that Planned Parenthood Southeastern Virginia is a teaching institution, and that persons in training, under strict supervision, may be involved in some aspects of your care.

No guarantee has been given to me as to the results that may be obtained from any services I receive. I know that it is my choice whether or not to have services. I know that at any time, I can change my mind about receiving medical services at Planned Parenthood.

I understand that if tests for certain sexually transmitted infections are positive, reporting of positive results to public health agencies is required by law.

I will be given referrals for further diagnosis or treatment if necessary. I understand that if referral is needed, I will assume responsibility for obtaining and paying for this care. I will be told how to get care in case of an emergency.

I understand that confidentiality will be maintained as described in Planned Parenthood Southeastern Virginia Notice of Health Information Privacy Practices. I consent to the use and disclosure of my health information as described in Notice of Health Information Privacy Practices.

I hereby request that a person authorized by Planned Parenthood provide appropriate evaluation, testing, and treatment (including a birth control drug or device, if I request it).

I hereby acknowledge receipt of Planned Parenthood Southeastern Virginia notice of health information privacy practices.

Signature of patient __________________________________________________________ Date _______________

I witness the fact that the patient received the above mentioned information and said she/he read and understood same and had the opportunity to ask questions.

Signature of witness _________________________________________________________ Date _______________

CHECK HERE IF PATIENT'S GUARDIAN OR RELATIVE IS LEGALLY REQUIRED TO SIGN BELOW

Signature of any other person consenting ____________________________________

Relationship to patient ___________________________________________________

Date _______________

I witness the fact that the patient's legal guardian (or person consenting in her behalf) received the above mentioned information and said she read and understood same.

Signature of witness _____________________________________________________