Request Form For Medical Services And Acknowledgement Of Receipt Of Notice Of Health Information Privacy Practices printable pdf download

Planned Parenthood Greater Memphis Region

2430 Poplar Avenue, Suite 100, Memphis, TN 38112 (901) 725-1717

REQUEST FOR MEDICAL SERVICES AND ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

PUT LABEL HERE

PATIENT # ____________________________

NAME OF PATIENT ___________________________________

DATE OF BIRTH ____________________________

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.

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

Greater Memphis Region 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-B-2a

Revised December 2012

PPGMR Manual of Medical Standards and Guidelines

Confidential property of Planned Parenthood Greater Memphis Region, Inc.

Request Form For Medical Services And Acknowledgement Of Receipt Of Notice Of Health Information Privacy Practices