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Get Planned Parenthood Proof Form in PDF

The Planned Parenthood Proof form is a document designed to collect essential information from patients seeking medical services at Planned Parenthood of Southeastern Virginia. This form ensures that individuals receive the appropriate care while maintaining their privacy and confidentiality. By providing detailed personal and medical information, patients can facilitate their healthcare experience and receive the necessary support and guidance.

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The Planned Parenthood Proof form serves as a crucial document for individuals seeking medical services related to pregnancy testing and reproductive health. This form collects essential personal information, including the patient's name, contact details, and emergency contact information, while ensuring confidentiality throughout the process. Patients are asked to indicate their preferred methods of communication for receiving test results, which can include phone calls or mail. Additionally, the form requires participants to provide details about their medical history, current symptoms, and reasons for seeking a pregnancy test. It also includes sections for assessing the patient's understanding of their rights and responsibilities, as well as a request for medical services and acknowledgment of privacy practices. Furthermore, the form emphasizes the importance of informed consent, ensuring that individuals are fully aware of the services they will receive and any potential risks involved. By gathering this information, Planned Parenthood aims to provide tailored care that meets the unique needs of each patient, while also promoting a safe and supportive environment for reproductive health services.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it's essential to ensure accuracy and clarity. Here are nine things to keep in mind:

Print Legibly: Write all information clearly to avoid misunderstandings.
Provide Accurate Information: Ensure all details, especially contact and medical history, are correct.
Use Preferred Pronouns: Indicate your preferred pronouns to help staff address you appropriately.
Check Contact Methods: Select how you prefer to be contacted regarding test results.
Explain Medical History: If you have any medical issues, provide clear explanations where needed.
Do Not Skip Questions: Answer all questions to the best of your ability; incomplete forms may delay services.
Avoid Assumptions: If unsure about a question, ask for clarification instead of guessing.
Do Not Use Nicknames: Use your legal name as it appears on official documents.
Do Not Rush: Take your time to fill out the form carefully; accuracy is more important than speed.

Document Attributes

Fact Name	Description
Organization	The form is provided by Planned Parenthood of Southeastern Virginia, with locations in Hampton and Virginia Beach.
Contact Information	The form includes contact numbers for both locations: (757) 826-2079 for Hampton and (757) 499-7526 for Virginia Beach.
Patient’s Bill of Rights	Patients acknowledge receipt of the Patient’s Bill of Rights and Responsibilities, ensuring they are informed of their rights.
Confidentiality Commitment	Planned Parenthood emphasizes their commitment to maintaining patient confidentiality throughout the testing process.
Medical Screening	The form includes a medical screening section, where patients provide details about their menstrual history and pregnancy symptoms.
Legal Reporting Requirements	In Virginia, if tests for certain sexually transmitted infections return positive, reporting to public health agencies is mandated by law.
Patient Consent	Patients must provide consent for medical services and acknowledge understanding of the health information privacy practices outlined by Planned Parenthood.

Key takeaways

When filling out and using the Planned Parenthood Proof form, keep these key takeaways in mind:

Legibility is crucial: Ensure all information is printed clearly to avoid any misunderstandings or delays in processing your request.
Contact preferences matter: Specify how you wish to be contacted regarding test results. This ensures you receive information in a way that feels comfortable and secure for you.
Honesty is essential: Provide accurate and complete information. Your healthcare choices depend on the details you share, so transparency is vital.
Understand your rights: Familiarize yourself with your rights regarding health information privacy and the services you can receive. Don’t hesitate to ask questions if anything is unclear.

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Example - 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 _______________

Detailed Instructions for Writing Planned Parenthood Proof

Filling out the Planned Parenthood Proof form is a straightforward process that ensures your information is accurately recorded for medical services. After completing the form, you can expect to receive guidance based on your responses, as well as further instructions regarding your care.

Print Legibly: Ensure that all information is written clearly to avoid any misunderstandings.
Check the Box: Indicate that you have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy by checking the box provided.
Fill in Personal Information: Enter your last name, first name, and middle initial. Provide your address, including apartment number, city, state, and zip code.
Employment and Contact Details: List your employer, email address (not for test results), and phone numbers for home, cell, and work.
Emergency Contact: Provide the name and phone number of someone to contact in case of an emergency.
Preferred Contact Method: Indicate how you would like to be contacted regarding test results by checking the appropriate boxes (phone call or mail).
Create a Password: Choose a password for receiving test results over the phone and write it in the designated space.
Complete Demographic Information: Fill in your date of birth, sex, monthly income, family size, and preferred pronoun.
Living Will: Indicate whether you have a living will by checking 'Yes' or 'No.'
Source of Referral: Select how you heard about Planned Parenthood from the provided options.
Race and Ethnicity: Mark your race and ethnicity as applicable.
Education Level: Indicate your highest level of education completed.
Medical Screening: Provide the date of your last menstrual period and answer questions about your current health status and history.
Assessment Section: This part is completed by clinic staff, so you may not need to fill this out yourself.
Sign and Date: Finally, sign and date the form to acknowledge your understanding and consent.

Documents used along the form

When seeking services from Planned Parenthood, various forms and documents may accompany the Planned Parenthood Proof form. Each document serves a specific purpose in ensuring that patients receive the necessary care while maintaining their rights and privacy. Below are some commonly used forms that you might encounter.

Patient’s Bill of Rights and Responsibilities: This document outlines the rights of patients receiving care, including the right to privacy, informed consent, and the ability to voice concerns or complaints. It ensures that patients are aware of their rights while receiving medical services.
Medical History Form: Patients often fill out this form to provide their medical background, including past illnesses, surgeries, and medications. This information helps healthcare providers understand the patient's health status and tailor care accordingly.
Consent for Treatment Form: This form is required for patients to give their consent for medical procedures or treatments. It ensures that patients are informed about the risks and benefits of the proposed care and agree to proceed.
Insurance Information Form: Patients may need to complete this form to provide details about their health insurance coverage. This information is essential for billing purposes and to determine the services covered under the patient’s plan.
Room Rental Agreement: This agreement is essential for outlining the terms of renting a room, ensuring both landlord and tenant understand their rights and obligations. For a comprehensive Room Rental Agreement template, check out NY Templates.
Referral Form: If a patient requires specialized care, a referral form may be used to direct them to another healthcare provider. This document includes details about the patient's condition and the reason for the referral, ensuring continuity of care.

These forms collectively support the patient experience at Planned Parenthood, ensuring that individuals receive comprehensive care while protecting their rights and privacy. Understanding these documents can help patients navigate their healthcare journey more effectively.