Patient intake form

Welcome to Planned Parenthood of Idaho!!
We appreciate you choosing Planned Parenthood of Idaho for your healthcare needs. To ensure that we have your current information in our system, we ask that you carefully fill out this form yearly (or sooner if anything has changed) and provide us with all the necessary information. Date:____________ Social Security Number: _______________________ Name: ____________________________________________________________________________________ Mailing Address: ___________________________________________________________________________ Phone Contact: _____________________________________________________________________________ Date of Birth : ____/____/______ Age:__________ Sex: M F Race (Optional): White Non-Hispanic (1)/ Multiracial Hispanic (10)/ Multiracial Non-Hispanic (9)/ Black Non-Hispanic (3)/ American Indian(5)/ Alaskan Native (6)/ Asian Pacific Islander Non Hispanic(7)/ Unknown (13) Other:_____________________________________ If under the age of 18, are your parents aware you are here today? □ Yes □ No
What birth control method are you currently using?: Condoms-Male or Female(NPB)/ Birth Control Pills (OC)/
Patch(PT) Nuva Ring (RI)/ Diaphram-Cervical Cap (PBM)/ Depo Provera (DP)/ IUD (IUD)/ Sterilization (ST)/ Natural Family
Planning (NF)/ Other (OT)/ No Method (NO)
How may we contact you? Mail ____________ Phone ____________ Both_____________
*Please Note: Planned Parenthood of Idaho will send statements to those patients over 18 years old with
outstanding balances. Planned Parenthood of Idaho may also need to send test results to the address
provided if patient is unavailable by phone. For most of the tests PPI provides, “No news is good news.”
Confidentiality may be broken if you cannot be contacted via the information you have provided, should a
life threatening condition be suspected or detected.
What services do you need today? Please describe:_________________________________________________
Emergency Contact:________________________________________________ Phone:_____________________
Would you like to give permission to PPI to dispense your medication to a friend/family member? □ Yes □ No Would you like to give permission to PPI to discuss or release your medical information to anyone besides you? □ Yes □ No Do you have Medicaid ____yes _____no Do you have health insurance ______yes ______no
*If you have Medicaid or Health Insurance please provide staff with your current card.
I UNDERSTAND THAT PAYMENT IS EXPECTED AT THE TIME OF SERVICE!! _______________
If you need financial assistance, please provide the following information. (you must provide the staff with proof of income such as a bank statement or pay stub.) Monthly Income ______________ Number supported by income _______________ Staff Initials __________ I assign my insurance benefits to Planned Parenthood of Idaho (PPI). I agree to pay for all charges not paid by the insurance company. I authorize PPI to release all or part of my medical records to any person or organization liable for payment. I accept responsibility for the medical charges incurred by the patient and agree to pay all bills at the time of service unless other arrangements are made. I certify that to the best of my knowledge, the above information is true. I request that a person authorized by PPI provide appropriate evaluation, testing and treatment. Patient Signature _______________________________________________ Date ________________________

Source: http://www.ppmarmonte.net/ppgnw/files/Great-Northwest/IDPatient_Intake_form.pdf