WV Family Planning Program - Policy Manual

Medical Director Signature 

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Table of Contents

4

General Administration

2

Legal Issues

1

Eligibility Guidelines

3

Clinic Management/Administration

7

Client Services

3

Required Clinical Services

70

Related Services

3

Quality Assurance

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Attachment A - Title X

Attachment B - Federal Register

Attachment C - WV Code

Attachment D - WV AIDS Prevention Centers

Attachment E - Public Health Service, HHS

Attachment F - 480 Federal Supplement

Attachment G - FPP Service Components by Categories

Attachment H - Prescribing Information

Attachment I - Patient Enrollment and Chart Set-Up

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Basic Data (L517)

Medical History (L518)

Progress Notes/Order Sheet (L519)

Client Education and Counseling Checklist (L561)

Consent for Deferred Physical Examination (L521)

Birth Control Pill Informed Consent (L525)

Depo-Provea Consent Form (L558)

Application for Implanon (L530)

Implanon Informed Consent (L526)

Consent for Emergency Contractive Pills (ECPS) (L520)

Intrauterine Device Informed Consent (L501)

Nuvaring Client Informed Consent (L527)

Ortho Evra Contraceptive Patch Informed Consent (L563)

Application for Voluntary Sterilization (L522)

Consent for Sterilization (HHS-687)

Attachments

Attachment A Pap Protocol

Attachment B Pap Protocol

Attachment G

Attachment H

General Resource Tools

Preconception Screen Counseling Checklist - 4/2009

Sexual Exposure Chart

Sterilization Information for Men - English (L150)

Sterilization for Women - English (L149)

Sterilization Information for Men- Spanish (L150-S)
Sterilization Information for Women- Spanish (L149-S)
Consent for Sterilization- Spanish (L553-S)

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Billing Instructions

Patient Data Form (L5501)

WV County Resident Codes

Sliding Fee Scale - July 2012

Invoice for Family Planning

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Forms

Supply Request Form (L529)

Literature Order Form 

Spanish Supply Request Form (L529)

Formulary

Exam & Labs

Instructions for the Collection, Submission Form and
     Mailing Of Chlamydia/Gonorrhea Urine Specimens

Instructions for the “Requisition Form for Specimen
     Mailing Kits"

Instructions for the Collection, Submission Form and
     Mailing of HIV Specimens

Diagnostic Immunology Laboratory Specimen Submission  

PCS Directions

PCS Internet Info

Pap Test Activity Log

Region III - Infertility Prevention Project

Statement of Drugs Administered to STD Clients

Family Planning Program Clinics

Implanon and Sterilization Providers

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