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Fill Out a Valid Planned Parenthood Proof Form

The Planned Parenthood Proof form is a document used by individuals seeking medical services, particularly related to pregnancy testing and reproductive health. This form collects essential personal information, medical history, and preferences for communication to ensure a comprehensive and confidential healthcare experience. To get started, fill out the form by clicking the button below.

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Table of Contents

Form Overview

Fact Name	Details
Organization	The form is provided by Planned Parenthood of Southeastern Virginia, which operates locations in Hampton and Virginia Beach.
Contact Information	Patients can reach the Hampton office at (757) 826-2079 and the Virginia Beach office at (757) 499-7526.
Patient’s Bill of Rights	Patients must acknowledge receipt of the Patient’s Bill of Rights and Responsibilities, ensuring they are informed of their rights during medical services.
Confidentiality Commitment	Planned Parenthood emphasizes the importance of maintaining patient confidentiality, especially regarding test results and personal information.
Medical Screening	The form includes sections for medical screening, where patients provide information about their menstrual cycle and any symptoms they may be experiencing.
Legal Compliance	In Virginia, certain laws require reporting positive results for sexually transmitted infections to public health agencies.
Patient Consent	Patients must provide consent for medical services, acknowledging their understanding of the procedures, risks, and their right to ask questions.

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Documents used along the form

When seeking services from Planned Parenthood, several forms and documents may accompany the Planned Parenthood Proof form. Each of these documents serves a specific purpose and is crucial for ensuring that patients receive the appropriate care while maintaining their rights and confidentiality. Below is a list of commonly used documents.

Patient’s Bill of Rights and Responsibilities: This document outlines the rights patients have while receiving care, including the right to privacy and informed consent. It also details the responsibilities of patients to provide accurate information and follow medical advice.
Patient Complaints Policy: This policy provides guidelines on how patients can voice concerns or complaints regarding their care. It ensures that patients feel heard and that their issues are addressed in a timely manner.
Request for Medical Services: This form is necessary for patients to formally request medical services. It confirms the patient's intent to receive care and provides a record of their request.
Acknowledgment of Receipt of Notice of Health Information Privacy Practices: Patients sign this document to acknowledge that they have received information about how their health information will be used and protected. It emphasizes the importance of confidentiality.
Medical History Form: This form collects essential information about a patient's medical history, including previous conditions, medications, and allergies. This information helps healthcare providers tailor care to the individual’s needs.
Consent for Treatment: Patients must sign this form to give their consent for specific treatments or procedures. It ensures that patients understand what they are consenting to and the associated risks.
Insurance Information Form: This document gathers details about the patient’s insurance coverage, which is necessary for billing purposes. It helps determine what services may be covered under the patient’s plan.
Emergency Contact Form: This form provides the clinic with the contact information of someone who can be reached in case of an emergency. It is vital for patient safety and ensures that someone can be notified if urgent medical decisions are needed.
Referral Form: If a patient requires additional services or specialists, this form facilitates the referral process. It ensures that patients receive comprehensive care without unnecessary delays.

Each of these documents plays a vital role in the care process at Planned Parenthood. Understanding their purpose can empower patients to navigate their healthcare more effectively, ensuring that their rights are protected and their needs are met.

Document Sample

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 _______________