Request to Receive Family Planning Services
Name ________________________________ Chart No: ______________________________
I hereby consent to receive medical and related services from staff of the North Dakota Family Planning (NDFPP) Program and telemedicine technologies may be utilized. I understand these services may include: review of my health history; health information, education and counseling; medical exam; screenings for breast and cervical cancer, mental health, Hepatitis C, behavioral risks and sexually transmitted infections including HIV; and referrals for care not provided at this clinic.
I understand that I have the right to receive free language interpreter services. I understand that I must tell the staff if these services will be helpful to my understanding of the written or spoken information given during my health care visits.
I understand that I will be provided information about the test(s), procedure(s), treatment(s) and family planning method(s) before any of these services are provided. I understand this information will include the benefits, risks, possible problems or complications and alternate choices. I understand I should ask questions about anything I do not understand.
I understand that my receipt of family planning services is voluntary. I can change my mind about receiving these services at any time. No guarantee has been given to me regarding the results that may be obtained from any services I receive. I know my acceptance of NDFPP services is not a prerequisite for receiving other services offered at this site.
I understand that I am eligible to receive services from this NDFPP clinic regardless of my religion, race, color, national origin, disability, age, sex, sexual orientation, gender identity, sex characteristics, number of pregnancies, marital status or inability to pay.
I also understand that my medical services and records will receive confidential treatment. My medical records can be disclosed to others only with my written consent or as otherwise required by law, such as reporting child abuse and neglect. If tests are taken for any sexually transmitted diseases, reporting of positive results from those tests to public health agencies is required by law. I understand my medical records may be shared with other NDFPP clinics for care at other NDFPP clinics of my choice.
My signature on this form indicates that I received or was offered a copy of the Notice of Privacy Practices. I understand that I may request a copy of the Privacy Notice anytime.
If my visit is covered by insurance or other third-party payers, I authorize NDFPP to release the medical information necessary to determine benefits payable under this claim. I authorize payment of medical benefits to the physician or supplier of services rendered. I understand I am financially responsible for this bill according to my pay category regardless of insurance coverage. I hereby certify that I have read and understand the above and voluntarily consent for the services and supplies provided by this clinic.
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Client Signature Date