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Free Planned Parenthood Proof Template in PDF

The Planned Parenthood Proof form is a document used by Planned Parenthood facilities to gather essential information from patients seeking medical services, particularly for pregnancy testing. This form ensures that patients are informed about their rights and responsibilities while also maintaining confidentiality throughout the process. For those looking to access these services, filling out the form is a crucial first step; click the button below to begin.

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Article Guide

Misconceptions

Misconceptions about the Planned Parenthood Proof form can lead to confusion and misinformation. Here are five common misunderstandings:

The form is only for women seeking abortions. This is incorrect. The Planned Parenthood Proof form is used for various services, including pregnancy tests and general reproductive health care.
Providing personal information is not necessary. In fact, accurate information is essential for effective care. The form collects data to ensure that patients receive appropriate medical services tailored to their needs.
Your information will not be kept confidential. Planned Parenthood is committed to maintaining confidentiality. The form explicitly states that your information will be protected and used only for medical purposes.
Test results are shared without consent. Patients have control over how they receive their test results. The form allows individuals to specify their preferred method of communication, ensuring they are comfortable with how they are contacted.
There is no opportunity to ask questions about the form. On the contrary, patients are encouraged to ask questions. The staff is available to clarify any concerns regarding the form or the services provided.

Documents used along the form

The Planned Parenthood Proof form is an essential document for individuals seeking medical services related to pregnancy testing and reproductive health. Along with this form, several other documents may be utilized to ensure comprehensive care and legal compliance. Below is a list of commonly associated forms and their purposes.

Patient’s Bill of Rights and Responsibilities: This document outlines the rights of patients receiving care, including the right to informed consent, privacy, and respectful treatment. It also details the responsibilities of patients in their healthcare journey.
Patient Complaints Policy: This form provides information on how patients can voice concerns or complaints about their care. It outlines the process for addressing grievances and ensures that patients feel heard and supported.
Request for Medical Services: This form is used to formally request medical services from Planned Parenthood. It includes patient information and consent for treatment, ensuring that patients understand the services they are requesting.
Acknowledgement of Receipt of Notice of Health Information Privacy Practices: This document confirms that patients have received and understood the privacy practices regarding their health information. It emphasizes the importance of confidentiality in healthcare.
Informed Consent Form: This form ensures that patients are fully informed about the tests, treatments, or procedures they will undergo. It details the benefits, risks, and alternatives to the proposed care.
Medical History Questionnaire: This form collects relevant medical history from patients, helping healthcare providers understand their background and tailor care accordingly. It includes questions about past medical conditions, medications, and family health history.
RV Bill of Sale: This document is necessary for the legal transfer of ownership of a Recreational Vehicle (RV) in Texas. It provides proof of sale and includes important details regarding the transaction, which can be found at https://toptemplates.info/bill-of-sale/rv-bill-of-sale/texas-rv-bill-of-sale.
Insurance Information Form: This document gathers details about the patient’s insurance coverage. It is essential for billing purposes and ensures that patients understand their financial responsibilities.
Consent for Release of Information: This form allows patients to authorize the sharing of their medical information with other healthcare providers or institutions. It is crucial for coordinated care and referrals.
Emergency Contact Form: This document collects information about individuals whom the healthcare provider can contact in case of an emergency. It ensures that the patient’s support system is informed and involved when necessary.

These forms work together to create a supportive and informed environment for patients. Understanding each document's purpose can enhance the overall experience and ensure that individuals receive the care they need while maintaining their rights and privacy.

Common mistakes

When filling out the Planned Parenthood Proof form, individuals often make several common mistakes that can lead to delays or complications in their care. One frequent error is failing to print legibly. The form explicitly requests that information be provided in a clear manner. Illegible handwriting can result in miscommunication, which may affect the quality of care received.

Another mistake is not providing complete contact information. The form asks for various phone numbers and an email address, yet some individuals may leave these sections blank or provide outdated information. This can hinder the clinic's ability to reach out with important test results or follow-up information.

Additionally, people sometimes overlook the importance of selecting preferred methods of communication. The form allows individuals to indicate whether they prefer to be contacted by phone or mail. Failing to check a box can lead to uncertainty about how they will receive sensitive information, which may cause unnecessary anxiety.

Another common oversight involves the section regarding medical history. Individuals may skip questions about previous pregnancies or current symptoms. This information is crucial for healthcare providers to make informed decisions. Incomplete medical histories can lead to missed diagnoses or inappropriate treatment options.

Some individuals also forget to provide a password for receiving test results over the phone. This password is essential for maintaining confidentiality and ensuring that sensitive information is shared securely. Without it, the clinic may be unable to disclose results in a timely manner.

Finally, many people neglect to sign and date the form. A signature indicates consent and understanding of the information provided. Without it, the form may be considered incomplete, which can further delay the process of receiving care. Ensuring that all sections are filled out accurately and completely is vital for a smooth experience at Planned Parenthood.

Sample - 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 _____________________________________________________