Planned Parenthood Proof Template

When filling out and using the Planned Parenthood Proof form, consider the following key takeaways:

• Print Legibly: Ensure that all information is filled out clearly and legibly. This helps prevent any misunderstandings or delays in processing.
• Confidentiality: The form emphasizes the importance of confidentiality. Understand that your information will be kept private, but there may be times when the clinic needs to contact you regarding test results.
• Contact Preferences: You can specify how you wish to be contacted for test results. Options include phone calls or mail. Providing a password for phone communications is also recommended.
• Medical History: Be prepared to answer questions regarding your medical history and current symptoms. This information is crucial for accurate assessment and care.
• Consent and Understanding: Before signing the form, ensure you understand all provided information. You have the right to ask questions and request clarification on any points that are unclear.

What is the Planned Parenthood Proof form used for?

The Planned Parenthood Proof form is primarily used for patients seeking medical services at Planned Parenthood of Southeastern Virginia. It collects essential information such as personal details, medical history, and contact preferences. This helps ensure that patients receive the appropriate care and follow-up based on their specific needs.

How is my confidentiality protected when I fill out this form?

Confidentiality is a top priority at Planned Parenthood. The information you provide on the Proof form is kept private and secure. Staff members are trained to handle your data with care. Communication regarding test results or other sensitive information will occur through methods you select, such as phone calls or plain mail, ensuring your privacy is respected.

Can I receive my test results over the phone?

Yes, you can receive test results over the phone, but you must provide a password on the form. This password is an additional layer of security to ensure that only you can access your results. If you choose this option, be sure to remember your password for future reference.

What should I do if I have questions about the form or my care?

If you have questions about the Proof form or your care, you are encouraged to ask staff members at Planned Parenthood. They are available to explain any parts of the form and address any concerns you may have. It’s important to understand all information provided to you to make informed healthcare decisions.

Guide to Using Planned Parenthood Proof

Completing the Planned Parenthood Proof form is an essential step in accessing healthcare services. This form collects important information that helps ensure your needs are met while maintaining your privacy. Follow these steps carefully to fill out the form accurately.

1. Print Legibly: Use a pen and write clearly to ensure all information is readable.
2. Check the Box: Indicate that you have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy by checking the appropriate box.
3. Fill in Personal Information: Provide your last name, first name, middle initial, address, apartment number (if applicable), city, state, and zip code.
4. Employer and Contact Details: Enter your employer's name, email address (note that it cannot be used for test results), home phone number, cell phone number, and work phone number.
5. Emergency Contact: Write the name and phone number of an emergency contact.
6. Preferred Contact Method: Check the methods you prefer for being contacted regarding test results—either by phone call or mail. Provide a password for receiving test results over the phone.
7. Demographic Information: Fill out your date of birth, sex, monthly income, family size, and preferred pronoun.
8. Living Will: Indicate whether you have a living will by checking yes or no.
9. Source of Referral: Select how you heard about Planned Parenthood from the provided options.
10. Race and Ethnicity: Mark your race and whether you identify as Hispanic.
11. Education Level: Indicate your highest level of education completed.
12. Medical Screening: Complete the section regarding your last menstrual period and any current symptoms or birth control usage.
13. Assessment: This section is typically completed by clinic staff, so ensure you have provided all necessary information for them to proceed.
14. Sign and Date: Finally, sign and date the form to acknowledge your understanding and consent.

Once the form is filled out, it will be reviewed by the clinic staff. They will use the information you provided to assist you effectively. Make sure to ask any questions if something is unclear. Your health and understanding are the top priorities.