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Patient Forms

You may download these forms and complete them prior to your appointment:

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

AUTORIZACIÓN PARA EL COMPARTIR INFORMACIÓN MEDICA

BIRTH CONTROL REFILL REQUEST 

SOLICITUD DE RESURTIDO ANTICONCEPTIVOS

MEDICATION ABORTION INFORMATION FORM

MEDICATION ABORTION INFORMATION FORM (SPANISH)

NON-DISCRIMINATION NOTICE  

AVISO DE NO DISCRIMINACIÓN 

SURGICAL ABORTION INFORMATION FORM

SURGICAL ABORTION INFORMATION FORM (SPANISH)

 

HIPAA Privacy

You may download these forms and review for privacy information:

NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES
This notice describes how health information about you may be used or disclosed by Planned Parenthood of Greater Ohio and how to access this information.

AVISO SOBRE PRÁCTICAS DE PRIVACIDAD RELACIONADAS CON INFORMACIÓN DE SALUD
Este aviso describe cómo la información relacionada con su salud puede ser usada o divulgada por las oficinas de Planned Parenthood of Greater Ohio y cómo puede usted tener acceso a dicha información por favor, lea este aviso detenidamente.

PATIENT HEALTH RECORDS REQUEST
For more information about requesting your patient health records, click here

 

No Surprises Act

Your rights and protections against surprise medical billing: click here

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