Planned Parenthood

Southern Finger Lakes

Medical & Financial Intake Forms

The Confidential Health History, Patient Contact form, Patient Financial form, Release of Medical Record form, Pregnancy Determination and Counseling form, and the Family Planning Benefit Program (FPBP) application are available for download. Click the links to download and print the forms you need,then fill out and bring the completed forms with you to your appointment.Please do not e-mail the forms to PPSFL.Each of the forms requires an original signature.

HIPPA Patient Privacy

HOPE

Female Confidential Health History

Historial de salud confidencial

Male Confidential Health History

Patient Contact Form

Informacion de contacto y estadistias

Release of Medical Records

Financial Assessment Form

Evaluacion Financiera

Forma de Autorizacion Para Divulgacion de Informacion Medica

Family Planning Benefit Program (FPBP)

Programa De Beneficios De Planificacion Familiar (FPBP)

If you want to use your insurance, please be sure to bring in your insurance information at the time of your visit.

If you are uninsured, you may qualify for a state-funded program (FPBP) or a lower fee scale. Please bring the following documents:

  1. birth certificate or passport (If you do not have your birth certificate, please bring the following documentation so we can help you obtain your birth certificate.)

  2. proof of current income (Last 4 weeks of pay stubs, copies of unemployment checks, copies of child support/alimony checks, or court order most recent tax return if self employed)

  3. photo ID (Student ID, Drivers License, etc.) proof of residence dated within the last 30 days (Utility bill in your name, lease,an envelope addressed to you and delivered to your physical address within the last 30 days-no window envelopes)

  • tumblr icon
  • google plus icon
  • twitter icon
  • rss icon
Medical & Financial Intake Forms