Planned Parenthood Proof PDF Form

The Planned Parenthood Proof form is a crucial document used to gather essential information from individuals seeking medical services, particularly related to pregnancy testing. This form ensures that patients receive the appropriate care while maintaining their confidentiality and rights. Understanding how to fill out this form accurately is vital for accessing the services you need.

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Overview

Common mistakes

Illegible handwriting: Filling out the form legibly is crucial. If the handwriting is difficult to read, it may lead to misunderstandings or delays in processing your information. Always take your time to write clearly.
Missing required fields: Be sure to complete all mandatory sections of the form. Leaving out essential information, such as your name or date of birth, can result in your application being delayed or rejected.
Incorrect contact preferences: When indicating how you wish to be contacted, make sure to check the correct boxes. If you prefer phone calls but check mail instead, you might miss important information.
Inaccurate medical history: Providing incorrect or incomplete medical history can affect your care. Always double-check your answers regarding past pregnancies, contraceptive use, and any symptoms you may be experiencing.
Not providing a password: If you want to receive test results over the phone, you must provide a password. Forgetting this step can lead to difficulties in accessing your results.
Ignoring confidentiality preferences: It’s important to communicate your preferences regarding confidentiality. If you don’t specify how you want your information handled, you may not receive the privacy you expect.

Similar forms

Informed Consent Form: Similar to the Planned Parenthood Proof form, an informed consent form outlines the details of medical procedures, ensuring patients understand the risks and benefits before agreeing to treatment. It emphasizes the patient's right to ask questions and make informed choices.
Power of Attorney Form: This crucial document grants an individual the power to make decisions on behalf of another in critical situations. Understanding its significance can enhance patient care and ensure that healthcare decisions align with the patient’s wishes, similar to the importance of the Missouri PDF Forms for legal arrangements.
Patient Registration Form: Like the Planned Parenthood Proof form, a patient registration form collects personal and demographic information. It serves to establish a patient's identity and contact details, which are essential for medical records and communication.
Medical History Questionnaire: This document is similar in that it gathers comprehensive information about a patient's past health and medical conditions. The goal is to inform healthcare providers about any relevant history that may affect current treatment or testing.
Privacy Notice Acknowledgment: This document parallels the Planned Parenthood Proof form by addressing the confidentiality of patient information. It ensures that patients are aware of their rights regarding the privacy of their health information and how it may be used or disclosed.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it is important to follow certain guidelines to ensure accuracy and clarity. Here are four things you should and shouldn't do:

Do print your information legibly. This helps avoid any misunderstandings or mistakes.
Do provide accurate and complete information. Your healthcare choices depend on the accuracy of the details you submit.
Don't skip any sections that apply to you. Omitting information could lead to delays or complications in your care.
Don't hesitate to ask questions if you don’t understand something. Clarifying doubts ensures you are fully informed about your health care options.

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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Misconceptions

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

This form is inclusive and designed for individuals of all genders. It recognizes that anyone may need reproductive health services, regardless of their gender identity.

Misconception 2: You must provide your email address for test results.

While the form asks for an email address, it explicitly states that it cannot be used for test results. This ensures privacy and confidentiality.

Misconception 3: Providing personal information is optional.

Most of the information requested on the form is necessary for providing appropriate medical care. Accurate details help ensure the best possible services.

Misconception 4: The form guarantees a specific outcome from the tests.

No guarantees are made regarding the results of any tests. The form clearly states that results may vary and that no specific outcome can be assured.

Misconception 5: You cannot change your mind about receiving services.

The form emphasizes that individuals have the right to change their minds at any time regarding medical services. Your choices are respected and upheld.

Misconception 6: Confidentiality is not prioritized.

Confidentiality is a key commitment. The form outlines how personal information will be protected, reassuring individuals that their privacy is taken seriously.

Misconception 7: You need a living will to proceed with testing.

While the form inquires about a living will, it is not a requirement for receiving services. This question is intended for understanding individual health care preferences.

Misconception 8: Only negative test results are discussed.

The form allows individuals to express their hopes for test results, whether negative or positive. It ensures that conversations about all outcomes are possible.

Misconception 9: You must have a partner to receive services.

Services are available to anyone, regardless of relationship status. The form includes questions about partners to understand individual circumstances better, not to limit access.

Misconception 10: The form is only for those seeking pregnancy tests.

This form serves multiple purposes, including assessments for various reproductive health services. It is not limited to just pregnancy testing.

How to Use Planned Parenthood Proof

Filling out the Planned Parenthood Proof form is an important step in accessing medical services. This form collects essential personal and medical information that helps ensure you receive the care you need. Follow the steps below to complete the form accurately and efficiently.

Print Legibly: Use a pen and write clearly to ensure all information is readable.
Check the Service: Indicate that you have received a copy of the Patient’s Bill of Rights and Responsibilities by checking the box provided.
Fill in Personal Information: Enter your last name, first name, and middle initial. Provide your complete address, including apartment number, city, state, and zip code.
Employment and Contact Details: List your employer, email address (note that this cannot be used for test results), and phone numbers (home, cell, and work).
Emergency Contact: Provide the name and phone number of someone to contact in case of an emergency.
Contact Methods: Indicate how you prefer to be contacted for results by checking the appropriate boxes (phone call or mail). Provide a password for receiving test results over the phone.
Personal Demographics: Fill in your date of birth, sex, monthly income, and family size. Choose a pronoun you prefer.
Living Will: Indicate whether you have a living will by checking 'Yes' or 'No.'
Referral Source: Select how you heard about Planned Parenthood by checking the appropriate options.
Race and Ethnicity: Indicate your race and whether you identify as Hispanic.
Education Level: Mark the highest level of education you have completed.
Medical Screening: Complete the section regarding your last menstrual period, any current symptoms, and reasons for the test.
History and Concerns: Answer questions regarding your medical history, current symptoms, and any concerns related to pregnancy or birth control.
Assessment: Leave the section for clinic staff to fill out regarding your medical assessment and test results.
Signature: Sign and date the form to acknowledge your understanding of the information provided.
Witness Signature: If applicable, have a witness sign and date the form as required.

Once you have completed the form, review it for accuracy before submitting it. This ensures that all information is correct and helps facilitate your visit to Planned Parenthood. If you have any questions or need assistance, don't hesitate to ask the staff for help.

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