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Download Planned Parenthood Proof Template

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 related to pregnancy testing. This form ensures that patients are informed about their rights and responsibilities while also maintaining their confidentiality. By completing this form, individuals can access the necessary healthcare services and support they need.

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Content Overview

The Planned Parenthood Proof form is a vital document that facilitates various medical services related to reproductive health, including urine pregnancy tests. This form collects essential information from patients, such as personal details, contact preferences, and medical history, ensuring that the healthcare providers can deliver appropriate care while maintaining confidentiality. Patients are asked to indicate their preferred methods of communication for receiving test results, which can include phone calls or mail. The form also includes sections for assessing the patient's current health status, menstrual history, and any potential signs of pregnancy. Additionally, it addresses sensitive topics such as contraceptive use and experiences of abuse, allowing for a comprehensive understanding of the patient's needs. By signing the form, patients acknowledge their understanding of their rights and responsibilities, as well as the privacy practices in place to protect their health information. This thorough approach not only enhances patient care but also fosters a supportive environment for individuals seeking reproductive health services.

Key takeaways

Key Takeaways for Using the Planned Parenthood Proof Form:

Fill out the form clearly and legibly. This ensures that all information is accurately recorded and understood by the staff.
Provide accurate contact information. This allows Planned Parenthood to reach you with important test results or updates.
Understand your rights. You will receive a copy of the Patient’s Bill of Rights and Responsibilities, which outlines your rights and the clinic's policies.
Know that your information is confidential. Planned Parenthood is committed to maintaining your privacy and will only share your information as necessary for your care.

Guide to Writing Planned Parenthood Proof

Completing the Planned Parenthood Proof form is an important step in receiving the necessary care and services. It is essential to fill out the form accurately and completely to ensure that your healthcare providers have the information they need to assist you effectively. The following steps will guide you through the process of filling out the form.

Print Legibly: Begin by ensuring that you have a pen and are ready to print your information clearly throughout the form.
Indicate the Test: Check the box next to "URINE PREGNANCY TEST" to confirm the type of test you are receiving.
Patient’s Bill of Rights: Confirm that you have received a copy of the Patient’s Bill of Rights and Responsibilities by checking the appropriate box.
Fill in Personal Information: Write your last name, first name, and middle initial. Then, provide your address, apartment number (if applicable), city, state, and zip code.
Employment and Contact Information: Include your employer's name, email address, home phone number, cell phone number, and work phone number.
Emergency Contact: Provide the name and phone number of a person to contact in case of an emergency.
Contact Methods: Indicate how you prefer to be contacted by checking the boxes for phone call or mail. Create a password for receiving test results over the phone.
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."
Referral Source: Describe how you heard about Planned Parenthood by checking the appropriate box.
Race and Ethnicity: Select your race and indicate whether you identify as Hispanic.
Education Level: Mark the highest level of education you have completed.
Medical Screening: Provide the date of your last menstrual period and answer whether it was normal. Explain if it was not.
Reason for Test: Check the box that corresponds to your reason for taking the test.
Desired Test Results: Indicate whether you hope for a negative or positive result, or if it doesn’t matter.
Current Symptoms: Answer the questions regarding any symptoms you are currently experiencing.
Birth Control Use: Indicate whether you are currently using birth control and specify the method if applicable.
History of Pregnancy: Answer the questions regarding your pregnancy history and any related concerns.
Assessment Section: This section will be completed by clinic staff, so you may leave it blank.
Signature: Sign and date the form at the bottom to confirm that you understand and agree to the information provided.

After you have filled out the form, it will be submitted to the clinic staff for processing. They will review your information and ensure that you receive the appropriate care based on your responses. If you have any questions or need assistance while filling out the form, do not hesitate to ask the staff for help. Your comfort and understanding are important throughout this process.

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Form Preview Example

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 _______________

Documents used along the form

When seeking medical services at Planned Parenthood, several documents may accompany the Planned Parenthood Proof form. Each of these forms serves a specific purpose, ensuring that your rights are protected and that you receive the appropriate care. Below is a list of commonly used forms that you may encounter.

Patient's Bill of Rights and Responsibilities: This document outlines your rights as a patient, including your right to receive respectful care, to be informed about your treatment options, and to privacy regarding your medical information.
Financial Evidence for Support: This document is essential for sponsors of immigrants, requiring proof of income and assets to demonstrate the ability to support the applicant financially. For more detailed information, you can refer to TopTemplates.info.
Patient Complaints Policy: This form explains the process for addressing any concerns or complaints you may have regarding the services received. It provides guidance on how to voice your feedback effectively.
Request for Medical Services: This form is necessary for you to formally request medical services. It includes your personal information and details about the services you wish to receive.
Acknowledgement of Receipt of Notice of Health Information Privacy Practices: This document confirms that you have received and understood the privacy practices regarding your health information, as mandated by law.
Consent for Treatment: This form provides consent for the medical staff to perform necessary evaluations, tests, and treatments. It ensures that you understand the procedures involved and agree to them.
Medical History Form: This form collects information about your past medical history, including any previous illnesses, surgeries, or medications. It helps the healthcare provider understand your health background.
Insurance Information Form: If you have health insurance, this document gathers your insurance details to facilitate billing and coverage verification for the services provided.
Emergency Contact Form: This form allows you to provide contact information for someone who can be reached in case of an emergency, ensuring that your needs are met promptly.
Release of Information Form: This document authorizes the sharing of your medical information with other healthcare providers or entities as necessary for your care.

Understanding these documents can help you navigate the process more smoothly. Each form plays a vital role in ensuring that your healthcare experience is respectful, informative, and tailored to your needs. If you have any questions about these forms, do not hesitate to ask the staff for clarification. Your comfort and understanding are paramount.