Request Form For Medical Services And Acknowledgement Of Receipt Of Notice Of Health Information Privacy Practices Page 2

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Planned Parenthood Greater Memphis Region
2430 Poplar Avenue, Suite 100, Memphis, TN 38112 (901) 725-1717
I hereby request that a person authorized by Planned Parenthood provide appropriate
evaluation, testing, and treatment (including a birth control drug or device, if I request it).
I hereby acknowledge receipt of Planned Parenthood Greater Memphis Region’s
notice of health information privacy practices.
Signature of patient _____________________________________________________
Date _______________
I witness the fact that the patient received the above mentioned information and said
she/he read and understood same and had the opportunity to ask questions.
Signature of witness _____________________________________________________
Date _______________
CHECK HERE IF PATIENT'S GUARDIAN OR RELATIVE IS LEGALLY
REQUIRED TO SIGN BELOW
Signature of any other person consenting ____________________________________
Relationship to patient ___________________________________________________
Date _______________
I witness the fact that the patient's legal guardian (or person consenting in her behalf)
received the above mentioned information and said she read and understood same.
Signature of witness _____________________________________________________
Date _______________
2
I-B-2a
Revised December 2012
PPGMR Manual of Medical Standards and Guidelines
Confidential property of Planned Parenthood Greater Memphis Region, Inc.

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