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PPINK Statement on Non-Discrimination

It is the policy of Planned Parenthood of Indiana and Kentucky to provide access to high-quality health care without discrimination against, or harassment of, any person on the basis of age, race, color, religion, sex/gender, gender identity or expression, sexual orientation, disability, pregnancy/number of pregnancies, contraceptive preference, genetic characteristics, ancestry, national origin, citizenship, residency, marital status, veteran status, or any other legally protected characteristic. Further, no patient will be denied service because of inability to pay.

 

Paperwork and Privacy

Once you've made your appointment, you can download forms here to save yourself time at the health center. By printing, filling out, and bringing your demographic information with you, you'll streamline your visit. Remember, medical privacy is very important to us at Planned Parenthood. We follow all HIPAA guidelines, and we will keep your visit confidential.

  • Download the Notice of Health Information Privacy Practices for your review prior to your visit. This form is for review only, no signature required.
  • Download the Demographic Form (Hoja Demográfica). On this form, we need your name, address, phone numbers, etc., as well as your insurance or Medicaid information, if any.
    • English (PDF)
    • English (PDF) – only for Elkhart, Gary, Michigan City, New Albany, and Seymour.
    • Español (PDF)
    • Español (PDF) – solamente para Elkhart, Gary, Michigan City, New Albany, y Seymour.

All new patients must complete the demographic form. If you do not bring it with you, you will be asked to fill it out at the health center.