West Virginia
Family Planning Program

FP Policy Manuals and Forms

FPP Policy Manual

WV Family Planning Program Guidelines - 2024

Providing Quality Family Planning Services in the U.S .

Recommendations of the U.S. Office of Population Affairs (Revised 2024)

Mandatory Program Forms

Client Education and Counseling Checklist

Data Collection Form

Medical History Form

Patient Information Form

Progress Notes and Order Sheet

Reproductive Life Plan

Sliding Fee Scale

Mandatory Billing Forms

Consent for Sterilization (English)

Consent for Sterilization (English large print)

Consent for Sterilization (Spanish)

Consent for Sterilization (Spanish large print)

HCFA 1500

IUD In-Take Form

Nexplanon In-Take Form

Sterilization In-Take Form

Pharmaceuticals and Supplies

Literature Order Form

Off-Formulary Request Form

Supply *Referral* Request Form

Supply Request Form

State Lab

Diagnostic Immunology Laboratory Specimen Submission Form

Supply Order Form for Diagnostic Immunology Collection Kits Thirty (30) Day Supply

Additional Information and Resources

Abnormal Cytology Test Results Log

Bypass Payment Invoice

Pregnancy Resources List

Program Formulary

Referral Services Template