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Fill a Valid Planned Parenthood Proof Template

The Planned Parenthood Proof form is a document used by patients to request medical services, including pregnancy testing, at Planned Parenthood facilities. This form collects essential personal information, medical history, and preferences for communication regarding test results. It is crucial for individuals seeking these services to complete the form accurately and legibly to ensure a smooth process.

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Fill a Valid Planned Parenthood Proof Template

Content Overview

The Planned Parenthood Proof form is an essential document designed to facilitate a range of medical services, particularly focused on pregnancy testing and related health assessments. This form not only collects personal information, such as names, contact details, and employment, but also addresses critical aspects of patient care, including medical history and current health concerns. Individuals seeking services are asked to indicate their preferred methods of communication for receiving test results, ensuring that confidentiality remains a priority. Furthermore, the form includes sections for medical screening, where patients can disclose their reasons for testing, any symptoms they may be experiencing, and their contraceptive history. It also provides an opportunity for patients to express their educational background and demographic information, which can help tailor services to their specific needs. The document emphasizes the importance of informed consent, ensuring that patients understand their rights and the nature of the services they are requesting. With this comprehensive approach, the Planned Parenthood Proof form aims to create a supportive environment for individuals navigating their reproductive health choices.

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Similar forms

Patient Intake Form: Similar to the Planned Parenthood Proof form, a Patient Intake Form collects essential information about a patient, such as personal details, medical history, and contact information. This document serves to establish a baseline for patient care and ensures that healthcare providers have the necessary data to offer appropriate services.
Consent for Treatment Form: This form is akin to the Planned Parenthood Proof form in that it requires patients to acknowledge their understanding of the treatment they will receive. Patients sign this document to confirm they are aware of the benefits, risks, and alternatives associated with the proposed medical services.
HIPAA Privacy Notice Acknowledgment: Like the Planned Parenthood Proof form, this document informs patients about their rights regarding personal health information. Patients must acknowledge their understanding of how their information will be used and protected, ensuring compliance with federal privacy regulations.
Hold Harmless Agreement: Similar to the Planned Parenthood Proof form, this document is critical in clarifying liability and protecting parties involved in transactions. It is often used to ensure that one party does not bear the legal risks associated with activities or agreements, such as the Hold Harmless Agreement in Arizona.
Medical History Questionnaire: This document is similar to the Planned Parenthood Proof form as it gathers detailed information about a patient’s past medical conditions, medications, and family health history. This information is crucial for healthcare providers to tailor treatments effectively.
Emergency Contact Form: Much like the Planned Parenthood Proof form, this document requests information about whom to contact in case of an emergency. It ensures that healthcare providers can reach a designated individual should any urgent situations arise during treatment.

Document Specifics

Fact Name	Description
Provider Information	The form is issued by Planned Parenthood of Southeastern Virginia, with locations in Hampton and Virginia Beach.
Contact Methods	Patients can choose how they prefer to be contacted regarding test results, including phone calls and mail.
Confidentiality Commitment	Planned Parenthood emphasizes the importance of maintaining patient confidentiality during the testing process.
Patient's Bill of Rights	Patients must acknowledge receipt of the Patient's Bill of Rights and Responsibilities, ensuring they understand their rights.
Legal Compliance	In Virginia, reporting positive results for certain sexually transmitted infections is required by law, ensuring public health safety.
Medical Screening	The form includes a medical screening section, where patients provide information about their health history and current symptoms.

Things You Should 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 gather essential information from patients seeking medical services, particularly related to pregnancy testing. It includes personal details, medical history, and consent for treatment.
What information do I need to provide on the form?
When filling out the form, you will need to provide your name, address, contact information, date of birth, and details about your medical history. This includes your last menstrual period, any current symptoms, and information about birth control usage. Additionally, you will be asked about your income and family size.
How is my privacy protected when I fill out this form?
Planned Parenthood is committed to maintaining your confidentiality. The form includes a section where you can indicate how you prefer to be contacted, such as by phone or mail. Test results will be communicated discreetly, often in a plain envelope or through secure methods.
Can I receive my test results via email?
No, you cannot receive test results via email. The form specifies that email cannot be used for this purpose. Instead, you can choose to receive results by phone or mail. If you prefer phone contact, you will need to provide a password for security.
What should I do if I have questions about the form?
If you have any questions while filling out the form, you are encouraged to ask the staff for clarification. They are there to help you understand the information and ensure that you are comfortable with the process.
What happens if I need an interpreter?
If you require language interpreter services to understand the information provided, it’s important to inform the staff. While free interpretive services may not always be available on-site, the staff will work to arrange the necessary assistance for your care.
What if I change my mind about receiving services?
You have the right to change your mind about receiving medical services at any time. The form clearly states that your choice to receive care is entirely up to you, and you can withdraw your consent if you wish.
Are there any legal obligations related to test results?
Yes, if tests for certain sexually transmitted infections return positive results, Planned Parenthood is legally required to report these results to public health agencies. This is done to help protect the health of the community.
What is the significance of the Patient’s Bill of Rights?
The Patient’s Bill of Rights outlines your rights as a patient, including the right to receive accurate information about your care, to ask questions, and to be treated with respect. Acknowledging this document ensures that you are aware of your rights and the responsibilities of the healthcare provider.

Documents used along the form

When seeking medical services from Planned Parenthood, several forms and documents may accompany the Planned Parenthood Proof form. Each of these documents serves a specific purpose to ensure that patients receive appropriate care while also protecting their rights and privacy.

Patient's Bill of Rights and Responsibilities: This document outlines the rights of patients receiving care, including the right to informed consent, confidentiality, and the ability to voice complaints. It also details the responsibilities patients have in their care process.
Transfer-on-Death Deed - This important document enables property owners in North Carolina to transfer their real estate to specified beneficiaries upon death, allowing for a smoother transition of assets without the complications of probate. For more detailed information, you can visit https://transferondeathdeedform.com/north-carolina-transfer-on-death-deed/.
Request for Medical Services: This form is a formal request for medical services and includes an acknowledgment of understanding regarding health information privacy practices. It ensures that patients are informed about their care options and the implications of their choices.
Health Information Privacy Practices Notice: This document explains how a patient's health information will be used and disclosed. It is crucial for maintaining confidentiality and ensuring compliance with legal standards regarding patient privacy.
Consent for Treatment: Patients must sign this form to indicate their consent to receive medical treatment. It details the procedures involved and confirms that the patient understands the risks and benefits associated with the proposed care.

These documents collectively enhance the patient experience by ensuring transparency, protecting rights, and fostering informed decision-making. Understanding each form's purpose can help patients navigate their healthcare journey more effectively.

Planned Parenthood Proof Preview

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 _______________