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The Planned Parenthood Proof form is an essential document for individuals seeking medical services related to pregnancy testing and reproductive health. It collects vital information from patients, including personal details such as name, address, and contact information, as well as medical history relevant to the pregnancy test. Patients must indicate their preferred methods of communication for receiving test results, ensuring confidentiality and comfort. The form also includes sections for medical screening, where clients provide information about their menstrual cycle, any symptoms they may be experiencing, and their contraceptive use. Furthermore, it addresses sensitive topics, such as past experiences with birth control and partner dynamics, allowing staff to assess the patient's overall health and well-being. Acknowledgment of the Patient's Bill of Rights and Responsibilities is required, emphasizing the importance of informed consent and understanding of the services provided. This form not only facilitates the testing process but also serves as a foundation for a supportive and respectful healthcare experience.

Key takeaways

Filling out the Planned Parenthood Proof form is an important step in receiving care. Here are key takeaways to keep in mind:

  • Print Legibly: Ensure all information is clear and easy to read. This helps avoid misunderstandings.
  • Confidentiality: Your privacy is a priority. Understand how your information will be kept confidential and how you may be contacted.
  • Contact Preferences: Indicate your preferred method of contact for receiving test results. You can choose between phone calls or mail.
  • Emergency Contact: Provide the name and phone number of someone who can be reached in case of an emergency.
  • Medical History: Be honest about your medical history, including any symptoms you may be experiencing. This information is crucial for accurate assessment.
  • Understanding Your Rights: Familiarize yourself with the Patient’s Bill of Rights and Responsibilities. This document outlines your rights as a patient.
  • Ask Questions: If you do not understand any part of the form or the process, do not hesitate to ask for clarification. Staff are available to help.
  • Interpreter Services: If needed, request interpreter services to ensure you fully understand the information provided during your visit.
  • Consent and Acknowledgment: Your signature on the form indicates that you consent to the services and acknowledge the receipt of privacy practices.

Taking the time to carefully complete the Planned Parenthood Proof form can lead to a smoother experience and better care. Your health and understanding are of utmost importance.

Documents used along the form

When seeking medical services, particularly in the context of reproductive health, various forms and documents are often required to ensure a comprehensive understanding of the patient's rights and responsibilities, as well as to maintain confidentiality. Below is a list of important documents that are commonly used alongside the Planned Parenthood Proof form.

  • Patient’s Bill of Rights and Responsibilities: This document outlines the rights that patients have during their healthcare experience, including the right to receive respectful care, to privacy, and to be informed about their treatment options.
  • Patient Complaints Policy: This policy provides information on how patients can voice concerns or complaints regarding their care, ensuring they have a clear avenue for addressing any issues that may arise.
  • Request for Medical Services: This form is necessary for patients to formally request medical attention. It typically includes personal information and details about the services needed.
  • Acknowledgement of Receipt of Notice of Health Information Privacy Practices: Patients sign this document to confirm they have received and understood the privacy practices that protect their health information.
  • Medical History Form: This form collects important background information about the patient’s health, including previous medical conditions, surgeries, and medications, which helps healthcare providers offer tailored care.
  • Informed Consent Form: This document ensures that patients understand the procedures and treatments they are consenting to, including any associated risks and benefits, before receiving care.
  • Trailer Bill of Sale: This document is vital for transferring ownership of a trailer, ensuring all parties have legal proof of the transaction. For more information, visit Formaid Org.
  • Emergency Contact Information Form: Patients provide details of an emergency contact person who can be reached in case of urgent situations, ensuring that appropriate measures can be taken if necessary.

Understanding these documents is crucial for patients as they navigate their healthcare journey. Each form serves a specific purpose in protecting patient rights and ensuring that individuals receive the care they need in a respectful and confidential manner.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it’s important to follow certain guidelines to ensure accuracy and clarity. Here’s a list of things you should and shouldn’t do:

  • Do print your information clearly to avoid any confusion.
  • Do check all applicable boxes, especially regarding contact methods.
  • Do provide accurate contact information to facilitate communication.
  • Do include a password for receiving test results over the phone.
  • Do indicate your preferred pronoun to ensure respectful communication.
  • Don't leave any required fields blank; this may delay your service.
  • Don't use abbreviations or shorthand when filling out the form.
  • Don't provide false information, as it can affect your care.
  • Don't forget to sign and date the form to confirm your consent.
  • Don't hesitate to ask for help if you don’t understand a question.

Common mistakes

Completing the Planned Parenthood Proof form can be straightforward, but many individuals make common mistakes that can lead to delays or complications. One frequent error is failing to print legibly. The form explicitly requests that information be printed clearly, yet many people overlook this requirement. Illegible handwriting can result in miscommunication and may require the form to be filled out again.

Another mistake is neglecting to provide complete contact information. Individuals often forget to include their email address or may provide an incorrect phone number. This information is crucial for receiving test results and other important communications. Omitting these details can hinder the ability of the clinic to reach out when necessary.

Many people also overlook the importance of checking the appropriate boxes. For instance, failing to indicate how they heard about Planned Parenthood or not selecting their preferred method of contact can lead to confusion. This oversight can affect the clinic’s ability to provide tailored services and follow-ups.

Another common issue arises with the date of birth section. Some individuals mistakenly enter the wrong date or leave this field blank. Accurate demographic information is essential for the clinic’s records and for ensuring that the patient receives appropriate care.

Additionally, individuals sometimes skip questions related to their medical history. For example, neglecting to answer whether they have a living will or if they are currently using birth control can lead to incomplete assessments. This information helps healthcare providers offer better guidance and support.

Another frequent oversight involves the consent section. People may forget to sign or date the form, which is critical for validating their consent to receive services. Without a signature, the form may be considered incomplete, causing delays in care.

Providing inaccurate information about income or family size is also a mistake that can affect eligibility for certain programs or services. Individuals should ensure that they accurately report their financial situation to avoid complications down the line.

Finally, failing to ask questions can be a significant error. If any part of the form or the process is unclear, individuals should feel empowered to seek clarification. Understanding the form fully ensures that patients can make informed decisions about their healthcare.

File Characteristics

Fact Name Description
Provider Information The form is issued by Planned Parenthood of Southeastern Virginia, with locations in Hampton and Virginia Beach.
Patient's Bill of Rights Patients must acknowledge receipt of the Patient’s Bill of Rights and Responsibilities, ensuring they understand their rights in the healthcare process.
Confidentiality Assurance Planned Parenthood commits to maintaining patient confidentiality while explaining potential communication methods for test results.
Medical Screening The form includes a section for medical screening, where patients provide information about their menstrual history and any current symptoms.
Legal Obligations Under Virginia law, positive results for certain sexually transmitted infections must be reported to public health agencies.
Consent for Services Patients must give informed consent, understanding the services provided and their right to ask questions or refuse care.

Form 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

TV

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

No

Are you currently experiencing?

 

Yes

No

 

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

No

 

 

Yes

No

 

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)

 

 

 

 

 

Advised re-test in 1-2 weeks

BCM Options

 

 

CIIC Contraceptive Implant

 

 

Prenatal Care

 

 

 

 

 

 

 

 

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 _______________