Blank 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, particularly for pregnancy testing. This form ensures that patients understand their rights and responsibilities while maintaining confidentiality throughout the process. By providing necessary details, patients can receive appropriate care tailored to their individual needs.

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Structure

Misconceptions

Misconception 1: The Planned Parenthood Proof form is only for women.

This form is designed for anyone seeking pregnancy testing services, regardless of gender identity. Transgender individuals can also utilize the services provided.

Misconception 2: The information provided on the form is not confidential.

Planned Parenthood is committed to maintaining confidentiality. The form outlines how personal information will be kept private and secure.

Misconception 3: You must provide an email address to receive test results.

The form clearly states that email cannot be used for test results. Alternative methods of communication are available, such as phone calls or mail.

Misconception 4: Providing personal information is optional.

While some sections may seem optional, accurate information is crucial for effective medical care. Patients are encouraged to provide complete and truthful responses.

Misconception 5: The form is only for those who are pregnant.

The form is used for individuals seeking pregnancy testing, which may include those who suspect they are pregnant or are experiencing symptoms related to pregnancy.

Misconception 6: You cannot change your mind after signing the form.

Patients have the right to change their minds about receiving services at any time, as stated in the consent section of the form.

Misconception 7: The form guarantees specific test results.

No guarantees regarding test results are provided. The form emphasizes that outcomes may vary and that a clinician will discuss results with the patient.

Detailed Steps for Filling Out Planned Parenthood Proof

Completing the Planned Parenthood Proof form is an important step in accessing medical services. This form gathers essential information to ensure that you receive the appropriate care. Follow the steps below to fill out the form accurately.

Print Legibly: Ensure all information is written clearly and legibly.
Check the Box: Indicate that you have received a copy of the Patient’s Bill of Rights and Responsibilities by checking the appropriate box.
Personal Information: Fill in your last name, first name, and middle initial.
Address: Provide your complete address, including apartment number, city, state, and zip code.
Employer and Contact Information: Enter your employer's name, email address (note that this cannot be used for test results), and phone numbers (home, cell, and work).
Emergency Contact: List the name and phone number of an emergency contact.
Contact Methods: Indicate your preferred methods of contact for test results by checking the appropriate boxes (phone call or mail). Provide a password for receiving test results over the phone.
Date of Birth and Sex: Fill in your date of birth and select your sex.
Income and Family Size: Indicate your monthly income and family size.
Pronoun: Select your preferred pronoun.
Living Will: Indicate if you have a living will by checking yes or no.
Referral Source: Specify how you heard about Planned Parenthood by checking the appropriate option.
Race and Ethnicity: Select your race and indicate if you identify as Hispanic.
Education Level: Check the highest level of education you have completed.
Medical Screening: Fill in the date of your last menstrual period and indicate if it was normal. Provide the reason for the test and the results you hope to see.
Current Symptoms: Answer questions regarding any symptoms you are currently experiencing and whether you are using birth control.
History of Issues: Indicate any relevant medical history or concerns related to pregnancy or birth control.
Signature: Sign and date the form to acknowledge your understanding of the information provided.

After completing the form, it will be reviewed by the clinic staff. They will ensure that all necessary information is gathered for your medical services. If you have any questions or need assistance, do not hesitate to ask the staff for help.

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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 _______________

Common PDF Templates

High School Transcript - Complete, accurate transcripts can greatly enhance a student's opportunities for higher education and employment.

Fake Dr Note - Verifiable proof of a medical professional's involvement in a patient's care.

How to Write a Payroll Check - A critical component in establishing payroll best practices.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it is important to follow certain guidelines to ensure accuracy and efficiency. Here are some dos and don’ts to keep in mind:

Do print legibly. Clear handwriting helps prevent misunderstandings.
Do provide complete information. Fill in all required fields to avoid delays in processing.
Do double-check your contact methods. Make sure you select how you prefer to be contacted for test results.
Do ask questions if something is unclear. Staff are available to assist you.
Don’t leave out important details. Omitting information can lead to complications in your care.
Don’t rush through the form. Take your time to ensure accuracy.

Key takeaways

1. Accurate Completion is Essential: All sections of the Planned Parenthood Proof form must be filled out completely and legibly. This includes personal information, contact details, and medical history. Inaccurate or incomplete information may delay services.

2. Confidentiality is a Priority: The form emphasizes the importance of maintaining confidentiality. Patients should be aware that their information will be handled with care and that communication about test results may occur through various methods, including phone calls and mail.

3. Understanding Health Information: Patients must acknowledge their understanding of the health information privacy practices. It is crucial to ask questions if any part of the information is unclear, ensuring informed consent for medical services.

4. Emergency Contact and Support: Providing an emergency contact is necessary. Patients should also consider their support systems, as discussions about sensitive topics, such as pregnancy or reproductive health, may require additional emotional support.

Similar forms

The Patient Intake Form is similar to the Planned Parenthood Proof form in that it collects essential personal information from a patient before they receive medical services. This document typically includes fields for the patient's name, address, contact information, and insurance details. Like the Planned Parenthood form, it ensures that the healthcare provider has the necessary information to offer appropriate care while also maintaining patient confidentiality. This form often serves as a first step in the healthcare process, allowing for a smoother experience during the visit.

The Medical History Questionnaire shares similarities with the Planned Parenthood Proof form by gathering comprehensive health information from patients. This document usually asks about past medical conditions, surgeries, allergies, and family health history. Just as the Planned Parenthood form assesses a patient's current health status and any relevant medical concerns, the Medical History Questionnaire provides healthcare providers with a clearer picture of the patient's overall health, which can influence treatment decisions.

The Consent for Treatment form is akin to the Planned Parenthood Proof form in that it requires patients to acknowledge their understanding of the services they will receive. This document typically outlines the procedures, risks, and benefits associated with the treatment. Like the Planned Parenthood form, it emphasizes the patient's right to ask questions and make informed choices about their healthcare, ensuring that they are fully aware of what to expect during their visit.

The Privacy Notice is similar to the Planned Parenthood Proof form as it informs patients about how their personal health information will be used and protected. This document typically outlines the rights patients have regarding their health information and the measures taken to maintain confidentiality. Just as the Planned Parenthood form reassures patients about the privacy of their information, the Privacy Notice reinforces the commitment to safeguarding sensitive data throughout the healthcare process.

The Authorization for Release of Information form mirrors the Planned Parenthood Proof form by allowing patients to designate who can access their medical records. This document usually requires patients to specify the individuals or organizations authorized to receive their health information. Similar to the Planned Parenthood form, it emphasizes the importance of patient consent in sharing personal health data, ensuring that patients maintain control over their information.

The Insurance Verification Form is comparable to the Planned Parenthood Proof form as it collects information necessary for processing insurance claims. This document typically requests the patient's insurance provider details, policy numbers, and coverage specifics. Like the Planned Parenthood form, it aims to streamline the administrative aspects of healthcare, ensuring that patients receive the financial support they need for their medical services while protecting their privacy.

Documents used along the form

When navigating healthcare services, especially those related to reproductive health, various forms and documents come into play. These documents help ensure that patients receive the necessary care while maintaining their rights and privacy. Below is a list of forms often used alongside the Planned Parenthood Proof form, each serving a specific purpose in the healthcare process.

Patient’s Bill of Rights and Responsibilities: This document outlines the rights patients have when receiving care, as well as their responsibilities. It ensures that patients are informed about their treatment options and the standards of care they can expect.
Patient Complaints Policy: This form provides information on how patients can voice their concerns or complaints regarding their care. It is essential for maintaining quality service and accountability within healthcare facilities.
Request for Medical Services: This form is used to formally request medical care or services. It includes details about the patient's needs and helps the healthcare provider understand what services are required.
Acknowledgment of Receipt of Notice of Health Information Privacy Practices: Patients sign this document to confirm they have received information about how their health information will be used and protected. This is crucial for maintaining confidentiality.
Medical History Form: This document collects important information about a patient’s medical history, including past illnesses, surgeries, and medications. It helps healthcare providers tailor their care to the patient’s needs.
Consent for Treatment: This form is essential for obtaining patient consent before any medical procedures or treatments are performed. It ensures that patients are aware of what to expect and agree to proceed.
Insurance Information Form: Patients fill out this form to provide details about their insurance coverage. This helps the healthcare provider determine the financial aspects of the care being provided.
Follow-Up Appointment Request: After an initial visit, this form allows patients to schedule follow-up appointments. It ensures continuity of care and helps patients stay on track with their health management.

Understanding these documents can empower patients to navigate their healthcare journey with confidence. Each form plays a vital role in ensuring that individuals receive the care they need while safeguarding their rights and privacy.