Planned Parenthood Of Hawaii Patient Registration Form

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PLANNED PARENTHOOD OF HAWAII
Patient Registration Form
PPHI recognizes that there is a spectrum of genders but many funding agencies and legal entities do not. Due to
circumstances beyond our control, please be aware that the legal name and sex you have listed on your funding source
must be used on documents pertaining to insurance and billing. If your preferred gender, name, and pronoun are different
from these, please let us know
Current gender identity  Male  Female  TG (MTF)  TG (FTM)
Legal gender  Male  Female
Preferred Name
_____________
________________
Preferred Pronoun ____________________________________________
First Name
MI
Last Name
How were you referred to this clinic
Are you a student
Street Address(Line1)
Circle one:
Yes
No
If you are a student, what type of student
Street Address(Line2)
Circle one:
Junior High
High School
College
Graduate School
City
State
Zip Code
What is the highest grade of school you completed
County
Citizen Status
Circle one:
U.S .Citizen
Refugee
Student Visa
Social Security Number
Tourist Visa
Immigrant Other
Compact States (Palau, Micronesia or
Date of Birth
Age
Marshal Islands)
Homeless Status
Home Telephone or Cell Phone
Are you homeless or living in a transitional shelter?
Work Telephone
Circle one:
Yes
No
Emergency Telephone # / Contact Name / Relationship
How will you be paying for this visit
Circle one:
Health insurance
Self-Pay
Who can we say is calling?
Do you have Health insurance
Circle one:
Yes
No
Circle one:
PPHI
Dana
Other Code Name
How can we send you mail?
Primary insurance:________________________________
Circle one: PPHI ID OK
PPHI Address Only
Subscriber #: ____________________________________
Email Address
Other insurance: _________________________________
Can you receive Email
Subscriber #: ____________________________________
Circle one:
Yes
No
Please remember that insurance may not cover all fees for
your services. It is your responsibility to pay any deductible,
Birth Gender
co-pay, or any other balance not paid by your insurance.
Circle one:
Male
Female
I authorize Planned Parenthood of Hawaii to release my
Ethnicity – Circle All That Apply:
medical records to any organization or agency which is or
may be liable for any portion of the charges for my service.
African American
Korean
Samoan
American Ind/AK Native
Laotian
Vietnamese
Signature: ______________________________________
Caucasian/White
Marshallese
Other Asian
Chinese
Micronesian
Other Pacific Isl.
Date of Signature: ________________________________
Filipino
Portuguese
Guamanian
Hawaiian/Part Hawaiian
Puerto Rican/Mexican/Cuban
Japanese
Hispanic Origin
Circle one:
Hispanic
Non-Hispanic
Marital Status
Circle one:
Divorced
Single
Live Together
Married
Widowed
Separated
12-12

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