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The Planned Parenthood Proof form serves as a critical document for patients seeking medical services at Planned Parenthood of Southeastern Virginia. This form encompasses essential information that helps ensure a smooth and confidential experience for individuals undergoing a urine pregnancy test. It begins by collecting personal details, such as the patient's name, address, and contact information, while also inquiring about their medical history and reasons for seeking the test. The form emphasizes the importance of patient confidentiality and provides options for how the clinic can communicate test results. Additionally, it includes sections that address the patient's reproductive health, including their current use of birth control and any symptoms they may be experiencing. The form also highlights the patient's rights, ensuring they understand their healthcare choices and the implications of the information they provide. With sections dedicated to medical screening and patient education, the Planned Parenthood Proof form not only facilitates the testing process but also empowers patients to engage in informed discussions about their health and reproductive options.

Similar forms

The Planned Parenthood Proof form shares similarities with a Medical History Form. Both documents require patients to provide personal information, including their medical history and current health status. This information is crucial for healthcare providers to offer appropriate care. Just like the Proof form, the Medical History Form often includes sections for medication lists, allergies, and previous surgeries, which help clinicians assess risks and tailor treatments effectively.

Another document akin to the Planned Parenthood Proof form is the Patient Consent Form. This form outlines the patient's rights and responsibilities while receiving care. It emphasizes the importance of informed consent, ensuring that patients understand the procedures and treatments they will undergo. Similar to the Proof form, the Patient Consent Form may also require signatures to confirm that the patient has received and understood the information provided, reinforcing the patient’s autonomy in their healthcare decisions.

The Insurance Information Form is also comparable to the Planned Parenthood Proof form. Both documents collect essential information that allows healthcare facilities to process claims and ensure coverage for services rendered. The Insurance Information Form typically asks for policy numbers, coverage details, and the policyholder’s information, paralleling how the Proof form gathers personal and contact details to facilitate communication and service delivery.

A Release of Information Form bears similarities to the Planned Parenthood Proof form as well. This document grants healthcare providers permission to share a patient’s medical information with other entities, such as specialists or insurance companies. Just like the Proof form, the Release of Information Form emphasizes the importance of confidentiality and patient consent, ensuring that patients have control over their health information.

The Patient Registration Form is another document that resembles the Planned Parenthood Proof form. Both forms collect demographic information, including name, address, and contact details, which are necessary for patient records. The Patient Registration Form may also include questions about emergency contacts and insurance, similar to the Proof form’s sections for contact preferences and income details.

A Treatment Authorization Form is similar to the Planned Parenthood Proof form in that it requires patients to authorize specific treatments or procedures. This document ensures that patients are informed about what they are consenting to, mirroring the Proof form's focus on patient education and understanding of medical services. Both forms reinforce the necessity of clear communication between healthcare providers and patients.

The Health Information Privacy Practices Acknowledgment Form shares characteristics with the Planned Parenthood Proof form as well. Both documents emphasize the importance of patient confidentiality and the handling of personal health information. The Privacy Practices Acknowledgment Form typically outlines how a healthcare provider will protect patient data, similar to how the Proof form reassures patients about confidentiality during their care.

In addition to the forms mentioned above, it's important to acknowledge the significance of maintaining proper documentation when transferring ownership of a boat. The California Boat Bill of Sale form provides a crucial legal framework for this process, protecting both parties involved by clearly detailing the transaction. For those interested in learning more about this form, you can visit californiapdffoms.com to ensure all necessary steps are followed for a smooth transfer of ownership.

The Patient Feedback Form can also be compared to the Planned Parenthood Proof form. While the Proof form gathers initial patient information, the Feedback Form collects insights on the patient’s experience after receiving care. Both documents aim to improve the quality of healthcare services, with the Feedback Form focusing on patient satisfaction and areas for improvement, while the Proof form sets the stage for effective communication and care delivery.

Finally, a Referral Form aligns with the Planned Parenthood Proof form in its function of facilitating patient care. Both documents are essential for ensuring that patients receive the appropriate services and follow-up care. The Referral Form typically includes details about the referring provider and the reason for the referral, paralleling the Proof form’s aim of gathering comprehensive information to guide treatment decisions.

Form Specifications

Fact Name Description
Organization This form is provided by Planned Parenthood of Southeastern Virginia.
Contact Information Two locations are available: Hampton, VA and Virginia Beach, VA. Phone numbers are (757) 826-2079 and (757) 499-7526 respectively.
Patient's Bill of Rights Patients must acknowledge receipt of the Patient’s Bill of Rights and Responsibilities, ensuring they understand their rights.
Confidentiality Commitment Planned Parenthood is committed to maintaining patient confidentiality, especially regarding test results.
Contact Methods Patients can choose how they would like to be contacted regarding test results, including phone calls and mail.
Medical Screening The form includes a medical screening section where patients provide details about their last menstrual period and any current symptoms.
Emergency Contact Patients are asked to provide an emergency contact name and phone number for any urgent situations.
Legal Compliance If certain sexually transmitted infections test positive, reporting to public health agencies is required by law.
Interpreter Services Patients may request interpreter services to ensure understanding of the information provided during healthcare visits.
Patient Consent Patients must consent to the use and disclosure of their health information as outlined in the Notice of Health Information Privacy Practices.

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 _______________