➼

Fill Out a Valid Planned Parenthood Proof Template

The Planned Parenthood Proof form is a document designed to gather essential information from patients seeking medical services, particularly related to pregnancy testing. This form ensures that individuals receive the appropriate care while maintaining their confidentiality and understanding of their rights. If you need to fill out the form, please click the button below.

Customize Document Online

Fill Out a Valid Planned Parenthood Proof Template

Contents

Form Specs

Fact Name	Details
Provider Information	Planned Parenthood of Southeastern Virginia has locations in Hampton and Virginia Beach.
Contact Methods	Patients can choose to be contacted via phone call or mail regarding test results.
Patient's Bill of Rights	Patients receive a copy of the Patient’s Bill of Rights and Responsibilities.
Confidentiality Commitment	Planned Parenthood is dedicated to maintaining patient confidentiality throughout the process.
Medical Screening	Clients complete a medical screening that includes questions about their menstrual cycle and pregnancy history.
Legal Reporting Requirement	If tests for sexually transmitted infections are positive, reporting to public health agencies is required by law.
Informed Consent	Patients must understand the information provided before consenting to medical services.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, there are several important considerations to keep in mind. Here’s a list of things you should and shouldn’t do:

Do print your information clearly. This helps avoid any misunderstandings.
Do provide accurate details about your medical history. This is crucial for your care.
Do indicate your preferred contact method for receiving test results. Choose what feels comfortable for you.
Do ask questions if anything is unclear. Your understanding is essential.
Don’t leave any required fields blank. Incomplete forms can delay your care.
Don’t share personal information that is not necessary for the form. Keep your information focused.
Don’t hesitate to use the space provided for additional comments. This can help clarify your situation.
Don’t rush through the form. Take your time to ensure everything is correct.

Common mistakes

Illegible handwriting: Many individuals rush through the form, leading to unclear or unreadable entries. This can cause delays in processing and may lead to misunderstandings about the patient's information.
Incomplete information: Some people forget to fill out all required fields, such as contact information or medical history. Omitting essential details can hinder the clinic's ability to provide appropriate care.
Incorrect contact preferences: Patients sometimes select contact methods that do not align with their preferences. For example, choosing email for test results when they prefer phone calls can lead to frustration and missed communications.
Misunderstanding medical history questions: Individuals may misinterpret questions regarding their medical history or current symptoms. This misunderstanding can result in inaccurate information being provided, which is critical for effective treatment.

Documents used along the form

When seeking medical services at Planned Parenthood, several important forms and documents are often utilized alongside the Planned Parenthood Proof form. Each of these documents serves a specific purpose in ensuring that patients receive the necessary care while also protecting their rights and privacy. Below is a list of these forms, along with brief descriptions of their functions.

Patient’s Bill of Rights and Responsibilities: This document outlines the rights and responsibilities of patients receiving care. It ensures that individuals are informed about their rights to privacy, respect, and informed consent during their medical visits.
Patient Complaints Policy: This policy provides a clear process for patients to voice any concerns or complaints regarding their care. It emphasizes the organization’s commitment to addressing issues and improving patient satisfaction.
Request for Medical Services: This form is essential for patients to formally request medical services. It includes consent for treatment and acknowledges the understanding of the procedures and potential risks involved.
Acknowledgement of Receipt of Notice of Health Information Privacy Practices: Patients sign this document to confirm that they have received and understood the privacy practices regarding their health information. It reinforces the commitment to confidentiality.
WC-200a Form: This form is essential for injured employees seeking to change their physician or request additional treatment by mutual consent between involved parties. More information can be found at https://georgiaform.com.
Medical History Form: This form collects vital information about a patient’s medical history, including previous illnesses, surgeries, and medications. It helps healthcare providers deliver tailored and effective care.
Informed Consent Form: This document ensures that patients understand the nature of the medical services they will receive, including any risks and benefits. Signing this form indicates that they agree to proceed with the treatment.
Emergency Contact Form: This form allows patients to designate someone to be contacted in case of an emergency. It ensures that healthcare providers can reach out to the right person if urgent decisions need to be made.

These forms work together to create a comprehensive framework that supports patient care while safeguarding individual rights and privacy. Understanding each document's purpose can help patients navigate their healthcare experience with greater confidence and clarity.

Misconceptions

Understanding the Planned Parenthood Proof form can be challenging, and several misconceptions may cloud the facts. Here are nine common misunderstandings, clarified for better insight.

Misconception 1: The form is only for women.

This is not true. The form accommodates all individuals seeking reproductive health services, including transgender and non-binary persons.

Misconception 2: Providing personal information is not necessary.

While it may feel uncomfortable, sharing accurate personal information is essential for providing appropriate care and ensuring your safety.

Misconception 3: Test results will be shared publicly.

Confidentiality is a priority. Test results are communicated privately, usually through secure methods like phone calls or plain envelopes.

Misconception 4: The form is too complicated to fill out.

The form is designed to be straightforward. It guides you through necessary sections, ensuring you can complete it with relative ease.

Misconception 5: You can’t change your mind about services.

Patients always have the right to change their minds regarding medical services at any point before receiving care.

Misconception 6: All medical staff are licensed professionals.

While many staff members are licensed, some may be trainees under supervision. This is a standard practice in teaching institutions.

Misconception 7: You must use your real name on the form.

Patients can use a pseudonym if they prefer, as long as it does not impede the provision of care.

Misconception 8: The form does not allow for questions.

Patients are encouraged to ask questions about anything they do not understand. Open communication is vital for effective healthcare.

Misconception 9: The form is only for pregnancy tests.

While pregnancy testing is a significant aspect, the form also addresses various reproductive health services, including contraceptive options and screenings.

Preview - 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 _____________________________________________________

Date _______________

Key takeaways

Understanding the Planned Parenthood Proof form is essential for a smooth experience. Here are key takeaways to keep in mind:

Print Legibly: Always fill out the form using clear and legible handwriting. This ensures that all your information is accurately recorded.
Contact Preferences: Indicate your preferred methods of contact for receiving test results. You can choose phone calls or mail.
Emergency Contact: Provide the name and phone number of an emergency contact. This person should be someone who can be reached if necessary.
Medical History: Be prepared to answer questions about your medical history and any current symptoms. This information is crucial for your care.
Privacy Assurance: Your confidentiality is a priority. Understand that your information will be kept private, in line with health privacy practices.
Interpreter Services: If you require language assistance, inform the staff. They will arrange for interpreter services if needed.
Consent for Services: You must consent to the services provided. Take the time to read the information carefully and ask questions if anything is unclear.
Right to Change Your Mind: Remember, you can change your mind about receiving services at any point. Your comfort and consent are paramount.

Filling out the Planned Parenthood Proof form accurately will facilitate your visit and ensure you receive the care you need.

Similar forms

Informed Consent Form: Similar to the Planned Parenthood Proof form, an Informed Consent Form outlines the information a patient must understand before undergoing medical procedures. It ensures that patients are aware of the risks, benefits, and alternatives to the proposed treatments.
Quitclaim Deed: This form is essential for transferring property ownership in Ohio and is typically used in familial or known-party situations. Understanding its proper use is crucial for seamless property transitions, and you can find the necessary documents at Ohio PDF Forms.
Patient Registration Form: Like the Planned Parenthood Proof form, a Patient Registration Form collects essential personal and contact information from patients. It serves to create a medical record and helps healthcare providers communicate effectively with patients.
Medical History Questionnaire: This document is akin to the Planned Parenthood Proof form in that it gathers detailed information about a patient's past medical history. It aids healthcare providers in understanding the patient's health background and making informed decisions.
HIPAA Acknowledgment Form: Similar in purpose, the HIPAA Acknowledgment Form informs patients about their rights regarding health information privacy. It ensures that patients understand how their information will be used and shared, much like the privacy practices outlined in the Planned Parenthood Proof form.
Release of Information Form: This document shares similarities with the Planned Parenthood Proof form by allowing patients to authorize the release of their medical records to other parties. It ensures that patients control who has access to their health information.