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Fill Out a Valid Planned Parenthood Proof Form

The Planned Parenthood Proof form is a document used by patients to request medical services and acknowledge their understanding of health information privacy practices. This form collects essential personal and medical information to ensure that patients receive appropriate care tailored to their needs. To get started, fill out the form by clicking the button below.

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Structure

The Planned Parenthood Proof form is an essential document designed to facilitate the provision of medical services, particularly in the context of pregnancy testing and related healthcare needs. This form captures vital patient information, including personal details such as name, address, and contact information, while also ensuring that patients are informed of their rights and responsibilities. Importantly, it addresses confidentiality, allowing patients to specify their preferred methods of communication for sensitive information. The form includes sections for medical screening, where patients can disclose their medical history and reasons for seeking a pregnancy test. It also provides an opportunity for patients to discuss any concerns regarding their reproductive health, including experiences of abuse or coercion. Additionally, the assessment section completed by clinic staff evaluates the results of the pregnancy test and offers educational resources based on those results. By ensuring that patients understand the services provided and the implications of their choices, the Planned Parenthood Proof form not only prioritizes patient autonomy but also fosters a supportive environment for individuals navigating complex healthcare decisions.

Common mistakes

Illegible handwriting: Many individuals fail to print legibly, making it difficult for staff to read critical information.
Incomplete personal information: Omitting essential details such as last name, first name, or date of birth can delay processing and communication.
Incorrect contact methods: Selecting inappropriate or outdated methods for contact can hinder timely communication regarding test results.
Missing emergency contact: Not providing an emergency contact name and phone number can complicate situations requiring immediate assistance.
Failure to indicate income: Leaving the monthly income field blank may affect eligibility for certain services or financial assistance.
Not specifying race or ethnicity: Some individuals neglect to complete these sections, which can impact data collection and service delivery.
Skipping medical history questions: Failing to answer questions about past pregnancies or medical conditions can lead to incomplete assessments.
Not providing a password for results: Omitting a password for receiving test results over the phone can create barriers to accessing important information.
Ignoring educational background: Not indicating the highest level of education completed can limit understanding of the patient's context and needs.
Inaccurate or incomplete consent: Not fully understanding or completing the consent section can lead to confusion regarding the services provided.

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 _____________________________________________________

Date _______________

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USCIS Form I-864 - Exceptions to the income requirement can sometimes apply in special circumstances.

Documents used along the form

When accessing services from Planned Parenthood, several forms and documents may accompany the Planned Parenthood Proof form. These documents help ensure that patients receive comprehensive care while maintaining their rights and privacy. Below is a list of commonly used forms.

Patient’s Bill of Rights and Responsibilities: This document outlines the rights and responsibilities of patients, ensuring they understand their entitlements regarding care and treatment.
Mobile Home Bill of Sale: This essential document facilitates the transfer of ownership of a mobile home, providing proof of the transaction and ensuring all parties involved are protected. For a template, refer to the Mobile Home Bill of Sale.
Patient Complaints Policy: This form provides information on how patients can voice concerns or complaints about their care, promoting transparency and accountability.
Request for Medical Services: Patients fill out this form to formally request medical services. It includes details about the services needed and confirms the patient's consent to proceed.
Acknowledgement of Receipt of Notice of Health Information Privacy Practices: This document ensures that patients are informed about how their health information will be used and protected, reinforcing confidentiality.
Medical History Form: Patients may be asked to complete this form to provide a comprehensive overview of their medical history, which helps healthcare providers deliver tailored care.
Consent for Treatment Form: This form is required for patients to consent to specific treatments or procedures, ensuring they understand what is being performed and any associated risks.
Insurance Information Form: Patients provide details about their insurance coverage, which assists in billing and ensures that services are covered under their plan.
Emergency Contact Form: This document collects information about whom to contact in case of an emergency, ensuring that appropriate measures can be taken if needed.

These documents work together to facilitate a smooth experience for patients at Planned Parenthood, ensuring that their rights are upheld and their health needs are met effectively.

Similar forms

The Patient Registration Form is similar to the Planned Parenthood Proof form in that it collects essential personal information from patients. This document typically includes fields for the patient's name, address, contact information, and insurance details. Just like the Planned Parenthood form, it aims to ensure that healthcare providers have accurate information to deliver appropriate care. The focus on patient confidentiality and the requirement for legible printing are also common features, emphasizing the importance of clear communication in a healthcare setting.

The Medical History Form serves a similar purpose by gathering a patient's medical background and current health status. It often includes questions about past illnesses, surgeries, and medications, mirroring the Planned Parenthood Proof form's inquiries about pregnancy history and current symptoms. Both documents are crucial for healthcare providers to understand a patient's health needs and to make informed decisions about their care. They also emphasize the importance of honesty and accuracy in the information provided.

The North Carolina Motor Vehicle Bill of Sale form is essential for documenting the transfer of vehicle ownership within the state. This legal document not only signifies the formal exchange but also provides vital details necessary for the buyer to register the vehicle. Key information such as the vehicle's make, model, year, VIN, sale price, and transaction date is meticulously recorded. For more information on how to complete this important form, you can visit https://autobillofsaleform.com/north-carolina-motor-vehicle-bill-of-sale-form.

The Informed Consent Form is another document that shares similarities with the Planned Parenthood Proof form. This form outlines the procedures or treatments a patient is consenting to, including the risks and benefits involved. Like the Planned Parenthood form, it requires a signature to confirm that the patient understands the information provided. Both documents prioritize patient autonomy, ensuring that individuals are making informed choices about their healthcare.

The Insurance Information Form is also comparable, as it collects financial details necessary for billing and coverage verification. This document typically asks for the patient’s insurance provider, policy number, and group number. Similar to the Planned Parenthood Proof form, it aims to facilitate the administrative aspects of healthcare, ensuring that patients receive the financial support they need for their medical services.

The Release of Information Form is akin to the Planned Parenthood Proof form in that it deals with patient confidentiality and the sharing of medical records. This form allows patients to authorize the release of their health information to specified individuals or organizations. Like the Planned Parenthood document, it underscores the importance of patient consent and confidentiality in managing personal health information.

The Appointment Confirmation Form shares a connection with the Planned Parenthood Proof form by ensuring that patients are aware of their scheduled visits. This document typically includes details such as the date, time, and location of the appointment, similar to how the Planned Parenthood form collects essential contact information. Both documents help streamline the patient experience and reduce the likelihood of missed appointments.

Lastly, the Follow-Up Care Instructions Form is similar in its focus on patient education and ongoing care. This document provides patients with guidelines on what to expect after a visit or procedure, including signs to watch for and when to seek further medical attention. Like the Planned Parenthood Proof form, it emphasizes the importance of communication between healthcare providers and patients to ensure proper understanding and adherence to care plans.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it’s important to ensure accuracy and clarity. Here are some essential do's and don'ts to keep in mind:

Do print your information clearly. This helps avoid any misunderstandings.
Do provide accurate contact information. This ensures that you can be reached with important test results.
Do ask questions if you don’t understand something. Clarifying doubts can help you make informed decisions.
Do review your answers before submitting. Double-checking can prevent errors that might delay your care.

Don't leave any required fields blank. Incomplete forms may lead to processing delays.
Don't use nicknames or abbreviations for names. Stick to your full legal name for clarity.
Don't hesitate to disclose your medical history. This information is crucial for your care.
Don't forget to sign and date the form. An unsigned form may not be valid.

Key takeaways

When filling out the Planned Parenthood Proof form, it is essential to follow these key takeaways:

Print Clearly: Ensure that all information is printed legibly. This helps avoid any misunderstandings or errors in processing your form.
Contact Preferences: Indicate your preferred methods of communication for receiving test results. You can choose between phone calls or mail.
Confidentiality Assurance: Your privacy is a priority. Planned Parenthood commits to maintaining confidentiality in handling your information.
Emergency Contact: Provide the name and phone number of an emergency contact. This is important for any urgent situations that may arise.
Medical History: Be honest and thorough when answering questions about your medical history, including any current symptoms or past issues.
Understanding Consent: Before signing, make sure you understand all the information provided. Don’t hesitate to ask questions if anything is unclear.
Interpreter Services: If you need language assistance, inform the staff. They can help arrange interpretive services, although it may take some time.
Review Privacy Practices: Familiarize yourself with the Notice of Health Information Privacy Practices. This document outlines how your health information will be used and protected.

Completing this form accurately and thoughtfully ensures that you receive the best possible care. Take your time, and do not rush through any section.

How to Use Planned Parenthood Proof

Completing the Planned Parenthood Proof form is an important step in accessing medical services. After filling out this form, your information will be processed, and you will be contacted regarding your test results or any necessary follow-up. Here’s how to fill out the form accurately:

Print the form clearly using a black or blue pen.
Check the box for the Urine Pregnancy Test.
Indicate that you have received a copy of the Patient’s Bill of Rights and Responsibilities.
Fill in your last name, first name, and middle initial.
Provide your complete address, including apartment number, city, state, and zip code.
List your employer and email address (note that the email cannot be used for test results).
Enter your home phone number, cell phone number, and work phone number.
Write the name and phone number of an emergency contact.
Choose your preferred methods of contact for results (phone call or mail).
Provide a password for receiving test results over the phone.
Fill in your date of birth and select your sex.
Indicate your monthly income and family size.
Choose a pronoun you prefer to use.
Indicate whether you have a living will.
Mark how you heard about Planned Parenthood.
Select your race and ethnicity, and indicate if you are Hispanic.
Specify your highest level of education completed.
Provide the date of the first day of your last menstrual period and indicate if it was normal.
State the reason for the test and the results you hope to see.
Answer questions regarding current symptoms, birth control usage, and any history of pregnancy-related issues.
Complete the assessment section if applicable, which may be filled out by clinic staff.
Sign and date the form at the bottom, acknowledging receipt of the Notice of Health Information Privacy Practices.
If required, have a guardian or relative sign and provide their relationship to you.