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Blank Planned Parenthood Proof PDF Form

The Planned Parenthood Proof form serves as a comprehensive document prepared by Planned Parenthood of Southeastern Virginia to record a variety of information including patient consent, medical screening outcomes, and contact preferences, ensuring patient rights and privacy are respected at every step. It details the procedures for obtaining medical services, acknowledging health information privacy practices, and also includes multiple sections for personal and medical data. Whether you are seeking a urine pregnancy test, medical screening, or need to establish a method of confidential communication, this form is designed to support your health and privacy needs. Ensure you fill out the form carefully by clicking the button below.

Content Overview

In today's world, where the intricacies of healthcare can often become overwhelming, understanding specific forms and procedures is crucial for individuals looking to navigate these systems effectively. The Planned Parenthood Proof form, utilized by Planned Parenthood of Southeastern Virginia, exemplifies this principle by serving as a comprehensive document that records a variety of vital information and consents relating to medical services and privacy practices. Key aspects of this form include clear instructions for patients to print legibly, checkboxes for the types of communication preferred, such as phone calls or mail, and sensitive questions about the patient’s health, sexual activity, and potential for pregnancy. It also delves into areas like a patient's medical history, contraception use, and even touches on sensitive topics such as domestic abuse, showcasing Planned Parenthood’s commitment to thorough patient care and confidentiality. Additionally, the form outlines the request for medical services and acknowledgment of receipt of Notice of Health Information Privacy Practices, ensuring that patients are fully informed about the kind of care they are consenting to and how their private information will be handled. This kind of form is vital in fostering an environment of trust and respect between healthcare providers and their patients, ultimately aiming to provide care that is both respectful and tailored to the individual's needs.

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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 _______________

➤ PDF File

Form Specifications

Fact Name	Description
Organization Name	Planned Parenthood® of Southeastern Virginia
Locations	Hampton and Virginia Beach, Virginia
Form Purpose	Request for Medical Services and Acknowledgement of Receipt of Notice of Health Information Privacy Practices
Contact Methods	Patient consent is required for contact via phone calls, email, text, and/or mail for the communication of test results or necessary information.
Confidentiality Commitment	Planned Parenthood is dedicated to maintaining patient confidentiality as outlined in their Notice of Health Information Privacy Practices.
Governing Law(s)	Virginia state law, specifically regarding the requirement to report certain sexually transmitted infections to public health agencies.

Planned Parenthood Proof: Usage Guidelines

Completing the Planned Parenthood Proof form is a necessary step in accessing certain services provided by Planned Parenthood® of Southeastern Virginia. It's important to fill out the form accurately to ensure that the healthcare team can provide personalized and effective care. Here are the steps to fill out the form correctly:

Check the box next to "URINE PREGNANCY TEST" if this is the test you are requesting.
Confirm receipt of the "Patient’s Bill of Rights and Responsibilities and Patient Complaints policy" by acknowledging in the provided space.
Print legibly your last name, first name, and middle initial in the designated areas.
Fill in your address details, including Apt #, City, State, and Zip Code.
Provide information about your employer and your email address (note: email cannot be used for test results).
List your contact information: Home Phone #, Cell Phone #, and Work Phone #.
Indicate your emergency contact name and phone number.
Select the preferred methods of contact (Phone Call or Mail) for receiving abnormal test results and provide a password for receiving test results over the phone.
Fill in your Date of Birth, select your Sex, and provide details about your Monthly Income, Family Size, Pronoun preference, and if you have a Living Will.
Answer the question on how you heard about Planned Parenthood.
Select your Race and Ethnicity, and indicate whether you are Hispanic.
Specify the Highest Level Of Education Completed.
Under the MEDICAL SCREENING section, completed by the client:
- Enter the 1st day of your last menstrual period and indicate if it was normal.
- Specify the Reason for Test and the Test Results you hope to see.
- Answer the questions about your current health status and history.
The ASSESSMENT section will be completed by clinic staff.
Sign and date the Request for Medical Services and Acknowledgment of Receipt of Notice of Health Information Privacy Practices section.

After completing and submitting the form, the Planned Parenthood team will review your information and proceed with the necessary evaluations and treatments as requested. This process is a vital part of ensuring personalized care based on your specific needs and health information.

Your Questions, Answered

What is the Planned Parenthood Proof form used for?

This form is used to document and acknowledge the receipt of medical services and the understanding of health information privacy practices at Planned Parenthood of Southeastern Virginia. It includes sections for personal details, medical screening questions, and consent regarding health information privacy.

How can I provide my contact information safely?

You can indicate your preferred methods of contact, including phone calls and mail, on the form. Planned Parenthood is committed to maintaining confidentiality and advises checking the methods safe for you.

What should I do if I need a language interpreter?

Inform the staff if you require interpreter services for better understanding during your health care visits. Be aware that interpreter services may not be immediately available, and a referral to another facility might be necessary.

Can someone assist me in my care if I am a minor?

Yes, if you are a minor, Planned Parenthood encourages parental involvement and may require consent from a guardian depending on the services requested and state laws.

What happens if I change my mind about receiving medical services?

You have the right to change your mind about receiving services at any time. Your choice will be respected and you can discontinue services as per your decision.

Is the information I provide guaranteed to be confidential?

Yes, Planned Parenthood assures that all information provided will be kept confidential as outlined in their Notice of Health Information Privacy Practices.

What happens if my tests for sexually transmitted infections are positive?

If tests for certain sexually transmitted infections are positive, reporting to public health agencies is required by law. You will also receive referrals for further diagnosis or treatment if necessary.

Who can sign the form if the patient is not able to?

If the patient is unable to sign for themselves, a guardian or relative legally required to consent can sign the form on the patient's behalf. Their relationship to the patient must be noted on the form along with a witness signature.

How do I acknowledge receipt of Planned Parenthood’s Notice of Health Information Privacy Practices?

By signing the form, you acknowledge that you have received and understood the Notice of Health Information Privacy Practices provided by Planned Parenthood Southeastern Virginia.

What should I do if I have any questions about the form or the services?

You should ask questions about anything you do not understand before signing the form. A clinician or staff member at Planned Parenthood will be happy to discuss any concerns or questions you may have about the form, the services, or your rights as a patient.

Common mistakes

When filling out the Planned Parenthood Proof form, people can make several common mistakes that may impact the processing of their form or the care they receive. It is crucial to avoid these errors to ensure accurate and efficient service.

**Not printing legibly**: It is essential to print all information clearly to avoid any confusion or misinterpretation of the data provided.
**Omitting the check for urine pregnancy test**: Forgetting to check the appropriate box for the urine pregnancy test can lead to delays in processing the form.
**Incomplete personal information**: Skipping fields such as Last Name, First Name, Middle Initial, and contact details can hinder Planned Parenthood's ability to record or contact individuals properly.
**Incorrect or missing contact preferences**: Failing to indicate preferred methods of contact or providing inaccurate contact information can complicate the communication process, especially when conveying test results.
**Not providing a password for phone results**: Neglecting to give a password for receiving test results over the phone compromises privacy and security.
**Leaving medical history sections blank**: Failing to complete sections related to medical history, including questions about symptoms or past conditions, can impact the care provided.
**Forgetting to check boxes related to medical screening**: Overlooking the necessity to check appropriate boxes under the medical screening questions can lead to incomplete medical records.
**Inaccurate income or family size information**: Misreporting monthly income or family size supported can affect eligibility for certain programs or services.
**Omitting educational background**: Not stating the highest level of education completed may be relevant for statistical purposes or specific care adjustments.
**Not acknowledging receipt of privacy practices**: Failing to sign the acknowledgment of the receipt of Notice of Health Information Privacy Practices might cause compliance issues.

By avoiding these common mistakes and ensuring all sections of the form are completed accurately and thoroughly, individuals can help Planned Parenthood provide the best possible care tailored to their specific needs.

Documents used along the form

When individuals utilise the Planned Parenthood Proof form, they are often engaging with a larger framework of healthcare services. This form is a crucial piece in ensuring individuals receive the comprehensive care they need, respecting their privacy and personal choices throughout the process. To support this, several other forms and documents may accompany the Planned Parenthood Proof form to provide a holistic approach to healthcare and administrative procedures.

Medical History Questionnaire: Collects detailed information about the patient's health history, including past illnesses, surgeries, and any ongoing treatments, to inform care decisions.
Consent Forms for Treatment: These forms are necessary for any medical procedures or treatments. They ensure that the patient understands the nature of the treatment, potential risks, and alternatives, giving informed consent.
Insurance Information Form: Captures information about the patient's insurance coverage, if applicable, which is essential for billing and determining the cost of services.
Privacy Notice Acknowledgment Form: Confirms that the patient has received a copy of the privacy practices, outlining how their personal health information will be used and protected.
Financial Assistance Application: For patients who may need help covering the cost of services, this document helps to assess their financial situation and eligibility for reduced fees or assistance.
Emergency Contact Information Form: Gathers details on whom to contact in case of an emergency during or after a procedure.
Sexual Health Assessment: A questionnaire that helps healthcare providers understand the patient's sexual health and any concerns or symptoms they may be experiencing, to provide appropriate advice and services.
Consent for Minor: If the patient is under the legal age for medical treatment without parental consent, this form must be completed by a parent or guardian, granting permission for care.
Follow-Up Care Instructions: After any procedure or test, this document provides patients with critical information on how to care for themselves, including any symptoms to watch for and when to seek further medical attention.
Medication Information Sheets: When prescriptions are provided, these sheets offer detailed information on how to take the medication, possible side effects, and any interactions with other drugs.

Together, these forms and documents ensure that patients are well-informed, their privacy is respected, and they receive the personalized care they deserve. The integration of these documents into patient care processes represents the comprehensive approach to healthcare that organizations like Planned Parenthood strive to provide. Ensuring patients' understanding and consent, safeguarding their health information, and addressing their financial concerns are all essential aspects of delivering quality healthcare services.

Similar forms

Medical Consent Forms: Similar to the Planned Parenthood Proof form, medical consent forms often gather personal information, including contact details, medical history, and consent for medical services and treatments. Both types of documents aim to ensure that patients understand the treatments or tests they will undergo and consent to them.
Patient Registration Forms: These forms, like the Planned Parenthood Proof form, collect demographic information such as name, address, and employment details. They are designed to record patient information at healthcare facilities for future communication and billing purposes.
Notice of Privacy Practices Acknowledgement Forms: Similar to sections of the Planned Parenthood Proof form, these documents outline how a patient's health information will be used and protected. They ensure that patients are aware of their privacy rights regarding personal health information.
Emergency Contact Forms: These forms, also part of the Planned Parenthood Proof document, collect information on whom to contact in an emergency. Both types of forms prioritize patient safety and preparedness for any urgent situations.
Informed Consent for Treatment Forms: Much like the Planned Parenthood document, these forms require patients to acknowledge that they have been informed about the benefits and risks of a specific treatment or procedure and consent to it. This process is fundamental in healthcare to ensure ethical and legal compliance.
Health Screening Questionnaires: These questionnaires, partially mirrored in the Planned Parenthood Proof form, collect information on a patient’s recent health history, symptoms, and concerns. They are used to assess the patient's current health status and determine necessary medical interventions.
Sexual Health History Forms: Similar to elements within the Planned Parenthood Proof document, these forms gather sensitive information related to sexual health and practices. They help healthcare providers offer appropriate care, advice, and treatment options related to sexual health.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it is essential to ensure that the process is done accurately and thoughtfully. Below are six things you should do and six things you shouldn't do to ensure the form is completed correctly.

Things You Should Do:

Print Legibly: Ensure all information is written clearly to prevent any misunderstandings or processing delays.
Double-Check Personal Information: Carefully review your name, address, and contact information for accuracy.
Be Honest: Provide truthful answers to all questions, particularly those relating to your medical history and current health status.
Use the Correct Checkboxes: Mark the appropriate boxes clearly, especially when indicating consent or choosing contact methods.
Sign and Date the Form: Your signature is mandatory, confirming your understanding and consent. Don't forget to date the form as well.
Ask for Clarification if Needed: If there's anything you do not understand, it's crucial to ask questions before signing the document.

Things You Shouldn't Do:

Leave Sections Blank: Do not skip any sections. If a section does not apply to you, write “N/A” to indicate this.
Forget to Indicate a Preferred Method of Contact: Failing to check your preferred contact method could lead to missed communications.
Use an Email for Test Results: The form clearly mentions that email cannot be used for test results, so ensure you provide alternative contact details.
Rush Through the Form: Take your time to read and understand each section fully before providing your information.
Assume Interpretation Services will be Immediately Available: If you need an interpreter, know that there might be a wait, and plan accordingly.
Sign Without Reading: Never sign the document without reading and understanding the Planned Parenthood Southeastern Virginia Notice of Health Information Privacy Practices first.

Misconceptions

Planned Parenthood provides a range of healthcare services and aims to ensure patient understanding and confidentiality throughout the care process. However, misconceptions about the Planned Parenthood Proof form and the organization's practices can often mislead or confuse individuals seeking care. Below, we discuss and clarify four common misconceptions:

Consent to Treatment Is Assumed at Planned Parenthood

Patients often believe that consent to treatment at Planned Parenthood facilities is automatically assumed. This is not accurate. The Planned Parenthood Proof form explicitly requires patients to acknowledge and sign, indicating their informed consent before receiving any medical services or treatments. This process ensures that patients are fully aware of the nature of the healthcare services provided, including the associated benefits, risks, and alternate choices available to them.
Patient Confidentiality Is Not a Priority

Some individuals mistakenly think that their personal information and treatment details might be easily accessed or disclosed without their consent. Contrary to this belief, Planned Parenthood is deeply committed to maintaining patient confidentiality. The organization adheres to strict privacy policies, as outlined in their Notice of Health Information Privacy Practices, which is acknowledged and signed by the patient. This document confirms that all personal health information is treated with the utmost confidentiality and is only shared in compliance with applicable laws and with patient consent.
Only Women Can Receive Services at Planned Parenthood

A common misconception is that Planned Parenthood's services are exclusively for women. However, Planned Parenthood offers a wide range of health care services to individuals of all genders, including men and transgender people. The Planned Parenthood Proof form asks about sex and preferred pronouns, acknowledging and respecting the gender diversity of their patients and catering to the healthcare needs of a broad patient demographic.
Lack of Immediate Medical Service Without Insurance

Another common misunderstanding is that individuals without health insurance cannot receive immediate medical services from Planned Parenthood. In reality, Planned Parenthood is dedicated to providing care to all individuals, regardless of their insurance status or ability to pay. The organization offers sliding scale fees based on an individual's income and family size to ensure that everyone has access to the healthcare services they require. This commitment is part of their mission to provide comprehensive and accessible reproductive health care and education.

Key takeaways

Filling out the Planned Parenthood Proof form is an essential step for individuals seeking medical services and acknowledging privacy practices at Planned Parenthood of Southeastern Virginia. Below are key takeaways to guide individuals through the process:

Personal Information: The form requires you to print legibly and provide comprehensive personal details, including your name, address, contact numbers, and email address (not for test results).
Communication Preferences: It allows you to specify preferred methods of communication, such as phone calls or mail, for maintaining confidentiality. You are also asked to provide a password for receiving test results over the phone.
Patient Rights and Responsibilities: By signing the form, you acknowledge receiving a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy, ensuring you are informed about your rights and duties as a patient.
Medical Screening Questions: The form includes sections for medical screening, where you'll answer questions related to your menstrual period, reasons for the test, and current birth control usage, among other health-related inquiries.
Pregnancy Test Details: For those taking a urine pregnancy test, the form captures the anticipated outcome, and whether you're experiencing any symptoms or have a history of certain medical conditions.
Assessment by Clinic Staff: There's a section designated for clinic staff to complete, including the pregnancy test result and patient education information, ensuring a comprehensive evaluation and guidance process.
Request for Medical Services: Signing the form also means you are formally requesting medical evaluation, testing, or treatment from Planned Parenthood, including any necessary birth control methodologies.
Acknowledgment of Privacy Practices: The form includes an acknowledgement that you have received the notice of health information privacy practices, consenting to the use and disclosure of your health information accordingly.
Consent and Signature: Your signature on the form is a crucial element, providing consent for evaluation, testing, and treatment. It may also include the signature of a witness or a legal guardian/relative where required.
Language and Interpretive Services: It indicates the availability of language interpreter services for those who need it to ensure understanding during health care visits, emphasizing Planned Parenthood's commitment to accessible care.

Completion of the Planned Parenthood Proof form signifies a patient's informed consent to receive services, along with an understanding of their rights and the privacy practices in place to protect their health information. It's a vital part of ensuring quality care and support for individuals utilizing Planned Parenthood’s services.