Patient Forms
Save time at the health center by downloading and completing the forms you need before your visit.
Iowa and Nebraska Health Centers
Medical Records Release Forms
Need a copy of your medical records? Please read the descriptions below and fill out the form that applies to you, then fax the completed form to 651-696-5543 or scan to [email protected].
- Medical Records Release TO Planned Parenthood-IA, NE (PDF)
Use this form if you want to send Planned Parenthood Iowa, Nebraska a copy of your records from another provider. Note: You don't need this form to switch between Iowa and Nebraska health centers. - Medical Records Release FROM Planned Parenthood-IA, NE (PDF)
Use this form if you want to send a copy of your Planned Parenthood Iowa, Nebraska medical records to another provider or third party. - Medical Records Release to Self-IA, NE (PDF)
Use this form to request a personal copy of your medical records. - Autorización para divulgación de informacIón a uno mismo - IA, NE
Usa este formulario para solicitar una copia personal de tu expediente médico.
Minnesota and South Dakota Health Centers
- No-Cost Birth Control Application (PDF)
No insurance? You may qualify for no-cost birth control at one of our Minnesota health centers. Fill out this form and bring it to your visit to apply.
Note: New immigration rules may apply to this program.
Medical Records Release Forms
Need a copy of your medical records? Please read the descriptions below and fill out the form that applies to you, then fax the completed form to 651-696-5543 or scan to [email protected].
- Medical Records Release TO Planned Parenthood-MN, ND, SD (PDF)
Use this form if you want to send Planned Parenthood Minnesota, North Dakota, South Dakota a copy of your records from another provider. Note: You don't need this form to switch between Minnesota, North Dakota, and South Dakota health centers. - Medical Records Release FROM Planned Parenthood-MN, ND, SD (PDF)
Use this form if you want to send a copy of your Planned Parenthood Minnesota, North Dakota, South Dakota medical records to another provider or third party. - Medical Records Release to Self- MN, ND, SD (PDF)
Use this form to request a personal copy of your medical records. - Autorización para divulgación de informacIón a uno mismo - MN, ND, SD
Usa este formulario para solicitar una copia personal de tu expediente médico.
Questions about which form to fill out? Give us a call at 1-800-230-7526.