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The Planned Parenthood Proof form serves multiple purposes in the context of patient care and administrative processes, encapsulating essential elements of medical intake, privacy, and consent all in one comprehensive document. Based in Southeastern Virginia, with facilities in Hampton and Virginia Beach, the form begins with a clear request for patients to provide information legibly, ensuring the accuracy of personal details such as name, contact information, and demographic data. This includes a specific section for a urine pregnancy test, alongside a patient's rights and responsibilities, indicating a commitment to informed consent and confidentiality. Additionally, the form prominently addresses various concerns ranging from the method of contact preference to detailed information about the patient's medical history, education level, income, and reasons for the test. Crucially, it mentions safeguards for maintaining confidentiality and outlines the process for dealing with abnormal test results. The document also includes an assessment section completed by clinic staff, alongside patient education on different results and follow-up actions. Importantly, the form concludes with a request for medical services and acknowledgment of receipt of health information privacy practices, ensuring patients understand their rights and the care they are consenting to. This multifaceted approach underscores Planned Parenthood's commitment to comprehensive care, patient privacy, and informed choice.

Sample - 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

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 _______________

➤ PDF Form

Form Information

Fact Name Description
Location Planned Parenthood of Southeastern Virginia, with locations in Hampton and Virginia Beach.
Contact Information Phone numbers provided for both Hampton and Virginia Beach locations.
Service Offered Urine Pregnancy Test, alongside a request to check the appropriate box for the service.
Patient Rights and Policies Patients receive a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy.
Confidentiality Commitment Patient is assured of confidentiality and given options for contact methods for test results.
Service Request and Acknowledgement Form Includes a section for the patient to request medical services and acknowledge receipt of health information privacy practices.
Medical Screening and Assessment Contains sections for medical screening completed by the client and assessment completed by clinic staff.
Consent and Legal Requirements Patient consents to evaluation, testing, and treatment, acknowledging that sexually transmitted infection positive results are reported to public health agencies as required by law.
Governing Law Laws of Virginia govern the form, compliance with state health reporting mandates.

Detailed Guide for Writing Planned Parenthood Proof

Completing the Planned Parenthood Proof form is a critical step in ensuring you receive the care and services that align with your needs. The form gathers basic personal information, medical history, consent for services, and privacy acknowledgments. By providing accurate details, you help the healthcare providers offer personalized support and maintain compliance with health privacy practices. Follow the steps below carefully to fill out the form correctly.

  1. Start by checking the box next to "URINE PREGNANCY TEST" if applicable.
  2. Read and confirm you have received the "Patient’s Bill of Rights and Responsibilities and Patient Complaints policy."
  3. Enter your last name, first name, and middle initial in the designated fields.
  4. Provide your address, including the apartment number if applicable, city, state, and zip code.
  5. If employed, include your employer's name.
  6. Fill in your email address, remembering it cannot be used for test results.
  7. Include your home phone number, cell phone number, and work phone number for contact purposes.
  8. Under the emergency contact section, write the name and phone number of someone who can be reached if necessary.
  9. Indicate preferred methods of contact (phone call, mail) by checking the appropriate boxes.
  10. For test results over the phone, create and provide a password.
  11. Complete the personal information section: Date of Birth, Sex, Pronouns, Monthly Income, Family Size Supported By, and if you have a living will.
  12. Detail how you heard about Planned Parenthood by checking the appropriate source and providing additional details if you select "Other."
  13. Select your race and ethnicity from the options provided.
  14. Indicate your highest level of education completed.
  15. In the MEDICAL SCREENING section, provide the first day of your last menstrual period and note whether it was normal or not. If not, explain briefly.
  16. Explain the reason for the test, your current birth control method if any, and any symptoms you're experiencing.
  17. Address the assessment questions about previous pregnancies, current pregnancy signs, or concerns about partner behavior.
  18. The last section should be filled out by clinic staff, so leave the assessment, test orders/results, patient education, and signatures sections blank for their completion.
  19. Finally, for the REQUEST FOR MEDICAL SERVICES AND ACKNOWLEDGEMENT section, fill in the date and sign to consent to the use and disclosure of your health information per the notice of health information privacy practices. If a guardian or relative's signature is legally required, ensure they sign and date the form in the designated areas.

Once you've carefully completed each step, review the form to ensure all information is accurate and complete. Submit the form to the Planned Parenthood staff. They will guide you through any additional steps and provide further instructions on upcoming appointments or services. Remember, clarity and accuracy in completing this form are essential for receiving tailored and timely healthcare services.

Important Points on Planned Parenthood Proof

What is the purpose of the Planned Parenthood Proof Form?

The Planned Parenthood Proof Form is designed to document the receipt and understanding of various policies, rights, and procedures related to the services being provided by Planned Parenthood of Southeastern Virginia. It covers a range of topics including consent to medical services, the confidentiality agreement, health information privacy practices, and acknowledges the patient's receipt and understanding of these practices.

How do patients receive their test results?

Patients can choose to receive their test results through phone calls or mail, according to the methods they check off on the form. It's important for patients to provide a password if they wish to receive results over the phone, ensuring that their information remains confidential.

Are there any confidentiality concerns with how Planned Parenthood contacts patients?

Planned Parenthood is committed to maintaining patient confidentiality. This is reflected in the way they contact patients — through methods pre-selected by the patients themselves to ensure privacy. Communications, especially ones containing sensitive results, are handled with the utmost care, often sent in plain white envelopes or conveyed through secure phone calls.

What does the form indicate about language interpreter services?

The form acknowledges the importance of understanding the information provided during health care visits and thus states that patients must inform staff if they require language interpreter services. It notes that while these services are available, they may not be immediate, and in some cases, referral to another facility may be necessary.

What are some key components of the medical screening section on the form?

In the medical screening section, the form captures detailed information from the client regarding their menstrual cycle, reasons for visiting, current symptoms of pregnancy or birth control use, and any history of reproductive health issues. This information helps Planned Parenthood provide tailored, appropriate medical advice and services.

What steps are suggested for negative pregnancy test results?

For negative test results, the form outlines a detailed follow-up procedure, which may include re-testing in 1-2 weeks, discussing the limitations of the initial test, exploring different types of contraceptive methods, and advising on what to do if no menstruation occurs for three consecutive months.

How does Planned Parenthood handle the teaching aspect of their services, as mentioned in the form?

The document mentions that Planned Parenthood Southeastern Virginia is a teaching institution where trainees may be involved in patient care under strict supervision. This reflects the organization's commitment to educating future healthcare providers while ensuring that patient care remains comprehensive and confidential.

Common mistakes

Completing forms accurately is critical, especially when it involves healthcare procedures like those provided by Planned Parenthood of Southeastern Virginia. There are several common mistakes individuals make on the Planned Parenthood Proof form that can affect the quality of care and communication received.

One significant error is not printing legibly. Since the form requests that information be printed legibly, unclear handwriting can lead to miscommunication about vital personal details, such as contact information or health history. This can hinder Planned Parenthood's ability to provide timely and accurate care or follow-ups.

Another frequent mistake is leaving sections incomplete. Skipping questions, especially those regarding contact preferences, medical history, and reason for the visit, can result in incomplete patient profiles, potentially affecting the care plan devised by healthcare providers. Furthermore, failing to indicate a preferred contact method can obstruct critical communication, particularly if test results need to be shared discreetly.

Individuals often neglect to check the appropriate boxes for questions that require a yes or no answer or to select from multiple-choice options, such as the 'Sex' and 'Ethnicity' categories. This omission can lead to inaccuracies in personal medical records and may impact the understanding of a patient’s health needs.

Providing an incorrect or outdated contact information is also a recurring problem. Since Planned Parenthood pledges to maintain confidentiality while needing to contact patients for follow-ups or test results, incorrect contact details can greatly impede necessary communication. Whether it's a moved address or changed phone number, such inaccuracies can result in missing crucial health information.

Not specifying a password for receiving test results over the phone is an oversight that affects privacy. Planned Parenthood may use a password system to ensure results are shared securely and only with the patient. Forgetting to provide a chosen password can delay the process of receiving personal test outcomes.

Finally, a common but critical error is failing to acknowledge receipt of privacy practices. The form's section on acknowledging understanding of Planned Parenthood’s health information privacy practices is essential, as it signifies the patient's consent and understanding of how their information will be used and disclosed. Overlooking this can raise privacy concerns and affect the patient's legal rights.

Ensuring all sections are completed accurately and thoroughly can significantly enhance the efficiency and effectiveness of the care provided by Planned Parenthood and safeguard patient privacy and communication.

Documents used along the form

When individuals engage with Planned Parenthood for healthcare services, they often need to provide or receive multiple forms and documents alongside the Planned Parenthood Proof form. Understanding these documents is crucial as they help in ensuring that the service provided meets the specific needs and legal requirements for each patient.

  • Health History Questionnaire: This comprehensive form collects detailed information about a patient's medical history, ongoing health conditions, past surgeries or hospitalizations, allergies, and family health history. It's essential for tailoring healthcare services to individual needs.
  • Consent for Treatment: Before any medical procedure or treatment begins, patients need to sign a Consent for Treatment form. This document explains the specific services to be provided, potential risks and benefits, and affirms the patient's agreement to proceed with the recommended treatment plan.
  • Notice of Privacy Practices: This document informs patients about how their health information may be used and disclosed by Planned Parenthood and their rights regarding their health information. It aligns with HIPAA regulations to ensure the confidentiality and security of personal health information.
  • Insurance Coverage Verification Form: Insurance information and verification are crucial for patients utilizing health insurance to cover services provided by Planned Parenthood. This form helps verify coverage details and understand any co-payments or deductibles that may apply.
  • Financial Assistance Application: For patients who may not have insurance or need help to cover the cost of services, Planned Parenthood offers a financial assistance application. By filling out this form, patients can provide information about their financial situation to qualify for reduced fees or payment plans.

These documents are designed to ensure that patients receive care that is not only effective but also respects their rights and meets their individual needs. By completing these forms, patients and healthcare providers create a foundation for open communication, informed consent, and confidentiality, which are crucial elements of quality healthcare services.

Similar forms

One document that bears resemblance to the Planned Parenthood Proof form is the Consent Form commonly used in medical practices. Similar to the Planned Parenthood form, a medical consent form collects personal details, informs the patient about the nature of the treatment, benefits, and risks, and seeks the patient's acknowledgment of understanding these points before proceeding with medical interventions. Moreover, both documents emphasize the importance of maintaining patient confidentiality and could involve consent pertaining to the treatment or procedures to be performed, underscoring the patient's autonomy in healthcare decisions.

Another analogous document is the HIPAA (Health Insurance Portability and Accountability Act) Privacy Notice, which healthcare providers are required to give to their patients. This notice, like the latter part of the Planned Parenthood form, educates patients on how their health information will be used and protected. It also explains the patient's rights concerning their personal health information. Both documents are integral in ensuring the patient is aware of and consents to privacy practices concerning their medical information.

The Intake Forms that patients typically fill out upon visiting a new healthcare provider also share similarities with the Planned Parenthood Proof form. These forms gather comprehensive personal and medical history, current symptoms, and other pertinent information to assist in patient care and treatment. Like the Planned Parenthood form, they represent an initial step in the treatment process, ensuring healthcare providers have the necessary information to offer personalized and effective care while also addressing any consent and privacy concerns.

Another document similar to the Planned Parenthood Proof form is a Patient's Bill of Rights, although the latter only refers to it rather than incorporating it fully. Patient's Bill of Rights documents outline the rights and responsibilities of patients within the healthcare system, including the right to respectful care, privacy, and information about one's health status and treatment options. Both kinds of documents serve to empower patients, ensuring they are duly informed and consent to their care regimen, underscoring the ethical delivery of healthcare services.

Lastly, the Medical Records Release Form shares commonalities with the Planned Parenthood Proof form in how it handles health information privacy and consent. This form authorizes the disclosure of the patient's health information from one healthcare provider to another or to the patient directly. Both documents deal with sensitive health information, requiring explicit consent from the patient to share this information, thereby safeguarding the patient's privacy and maintaining trust in the healthcare provider-patient relationship.

Dos and Don'ts

When filling out the Planned Parenthood Proof Form, there are specific actions you should take to ensure the process is smooth and accurate. Below are lists of what you should and shouldn't do:

Things You Should Do:
  • Print Legibly: Make sure your handwriting is clear and readable to avoid any confusion or errors in your documentation.
  • Check the Appropriate Boxes: Be certain to review each item carefully and check the box that applies to your situation or answer.
  • Provide Accurate Information: Ensure all data, including names, addresses, phone numbers, and medical history, is correct and current.
  • Use the Method of Contact You Prefer: Indicate your preferred method of contact by checking the appropriate box and provide a password for phone communication if required.
  • Review the Patient Rights and Responsibilities: Understand your rights as a patient and the clinic's responsibilities to you before signing the form.
  • Sign and Date the Form: Do not leave the signature and date sections blank. Your signature is necessary to validate the form.

Things You Shouldn't Do:
  • Leave Sections Blank: Do not skip any sections. If a section does not apply, mark it as N/A (Not Applicable) instead of leaving it empty.
  • Guess on Medical Information: If you are unsure about a medical question, it's better to check your records or consult a healthcare provider than to guess.
  • Use an Email Address for Test Results: According to the instructions, email addresses cannot be used for test results, so ensure you provide a preferred alternative method.
  • Ignore Instructions on Confidentiality: Take note of the instructions regarding how Planned Parenthood will maintain your confidentiality and communicate with you.
  • Forget to Provide a Method of Contact: You must indicate how the clinic can reach you for test results or additional information.
  • Rush Through the Form: Take your time when filling out the form to avoid mistakes and ensure all information is provided accurately.

Misconceptions

There are several misconceptions surrounding the Planned Parenthood Proof form. These misconceptions often stem from misunderstandings or misinformation about the form's purpose, the information it collects, and Planned Parenthood's policies on confidentiality and consent. Highlighting these misconceptions can help clarify what the Planned Parenthood Proof form is and what it is not. Below are four common misconceptions:

  • Misconception 1: The form is only used for pregnancy tests. While the document includes sections relevant to urine pregnancy tests, it is a comprehensive intake form used for various medical services offered by Planned Parenthood. This form gathers essential information about the patient's health history, reason for visit, contact preferences, consent to treatment, and acknowledgment of receipt of health information privacy practices. These aspects are critical to providing patient-centered care across the range of services offered.
  • Misconception 2: Personal information is shared widely. One of the form's primary purposes is to ensure confidentiality and privacy for patients seeking services at Planned Parenthood. It specifies the methods by which the clinic can safely contact the patient, such as through phone calls or mail, and even allows for a password to be set for receiving test results over the phone. This approach underscores Planned Parenthood's commitment to maintaining patient confidentiality and privacy.
  • Misconception 3: The form allows Planned Parenthood to use information for marketing purposes. The form clearly is designed to collect information necessary for providing medical care and understanding the patient's health needs. There is an acknowledgment section where patients consent to the use and disclosure of their health information, strictly adhering to Planned Parenthood Southeastern Virginia's Notice of Health Information Privacy Practices. This focus is on patient care and privacy, not marketing.
  • Misconception 4: Consent given through the form is permanent and cannot be revoked. The document adequately explains that receiving medical services at Planned Parenthood is entirely voluntary, and patients can withdraw their consent or change their minds at any time. This flexibility ensures that patients feel comfortable and in control of their health care decisions, reinforcing the ethical commitment to patient autonomy.

Understanding the Planned Parenthood Proof form and dispelling these misconceptions are vital in ensuring individuals seeking services feel informed and secure in their healthcare choices. The form is an important tool in facilitating trusted communication between patients and providers, aiming to deliver safe, confidential, and compassionate care.

Key takeaways

When filling out and using the Planned Parenthood Proof form, it's essential to understand several key points to ensure that the process is carried out smoothly and effectively. Here are some vital takeaways:

  • Complete the form accurately: It's important to print legibly and provide accurate information regarding your personal details (name, address, contact information), medical history, and specific concerns or reasons for the test. This information guides the healthcare providers in offering the most appropriate care.
  • Consent and privacy: Understand your rights and responsibilities as a patient, which includes receiving a copy of the Patient’s Bill of Rights and the Acknowledgement of Receipt of Notice of Health Information Privacy Practices. Consent to medical services implies an agreement to the use and disclosure of health information as outlined in the privacy practices.
  • Communication preferences: Indicate your preferred methods of contact for receiving test results or follow-up communication. Planned Parenthood is committed to maintaining confidentiality and will respect your choices, whether via phone call, mail, or other means, ensuring sensitive information is handled discreetly.
  • Understanding services and consent: Before signing the form, confirm your understanding of the tests, treatments, or procedures to be provided, including benefits, risks, and alternate options. It’s your right to ask questions and seek clarification on anything unclear. Remember, receiving services is voluntary, and you can change your decision at any time.

Remember, the information you provide on the Planned Parenthood Proof form plays a critical role in the care you receive. Ensuring the form is filled out comprehensively and accurately can significantly impact your health services experience. If you have concerns or require clarification at any point, do not hesitate to speak with the clinic staff.

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