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How to fill out the Planned Parenthood enrollment form online
This guide provides clear and supportive instructions for filling out the Planned Parenthood enrollment form online. By following the steps outlined below, users can successfully enroll in the contraceptive supply program and ensure timely delivery of their medications.
Follow the steps to complete the enrollment form with ease.
- Click the ‘Get Form’ button to obtain the enrollment form and open it for completion.
- Begin by entering your date of birth (DOB) in the designated field.
- Provide your full name as it appears on your identification.
- Enter your mailing address for refills, ensuring to include your city, zip code, and state (North Carolina).
- Fill in your telephone number, which will be used for any questions related to your order.
- Indicate your preferred payment method by circling Visa or Mastercard.
- If you consent to be identified as a member of Planned Parenthood, mark the appropriate box for 'Yes' or 'No'.
- Input your credit card number in the provided field, separating it using dashes for clarity.
- Fill out the expiration date of your credit card and the CV2 data, which is the last three digits on the back of your card.
- Authorize Planned Parenthood to charge your credit card by writing in the amount to be charged each time your birth control method is mailed, along with the $1.00 handling fee.
- Acknowledge that your enrollment will remain active for the duration of your current prescription, and that you can cancel by contacting Planned Parenthood.
- Finally, write the enrollment date and sign the form to confirm your application.
- Once completed, review your form for any errors before submitting it.
- You can save your changes, download a copy, or print the form for your records.
Complete your enrollment form online today to ensure a smooth experience with your contraceptive supplies.
You can visit Planned Parenthood without a referral from another provider. This flexibility makes it easy for you to access necessary health services on your terms. Whether you need birth control, STI testing, or other services, you can walk in or schedule an appointment directly. For those interested, US Legal Forms offers resources to help you navigate the process smoothly.
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