Hiv Consent Form - Pro Financial Services

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HIV Consent Form
LLOYD’S OF LONDON / PRO FINANCIAL SERVICES, LLC
Insurer:
Address:
500 West Madison Street, Suite 2660, Chicago, Illinois 60661
NOTICE AND CONSENT FOR AIDS-RELATE BLOOD TESTING
To evaluate your insurability, the Insurer named above (the Insurer) has requested that you provide a sample of
your blood or oral specimens obtained for testing and analysis to determine the presence of human
immunodeficiency virus (HIV) antibodies. By signing and dating this form you agree that this test may be done
and that underwriting decisions will be based on the test result. A series of three tests will be performed by a
licensed laboratory through a medically accepted procedure according to approval by the Federal Food and Drug
Adminstration.
HIV Antibody Test
Information For Insurance Applicant
AIDS:
Acquired Immunodeficiency Syndrome (AIDS) is a life-threatening disorder of the immune system, caused by a
virus, HIV. The virus is transmitted by sexual contact with an infected person, from an infected mother to her
newborn infant or by exposure to infected blood (as in needle sharing during IV drug use). Persons at high risk of
contracting AIDS include males who have had sexual contact with another male, intravenous drug users,
hemophiliacs and persons who have had sexual contacts with any of these persons. AIDS does not typically
develop until a person has been infected with HIV for several years. A person may remain free of symptoms for
years after becoming infected. An infected person has a significant chance of developing AIDS over the next 10
years.
The HIV Antibody Test:
Before consenting to testing, please read the following important information:
1.
Purpose: This test is being run to determine whether you may have been infected with HIV. If you are
infected, you are probably not insurable. This test is not a test for AIDS; AIDS can only be diagnosed by
medical evaluation.
2.
Positive Test Results: If you test positive, you should seek medical follow-up with your personal
physician. If your test is positive, you may be infected with HIV.
3.
Accuracy: An HIV test will be considered positive only after confirmation by a laboratory procedure that
the state health officer has determined to be highly accurate. Nonetheless, the HIV antibody test is not
100% accurate. Possible errors include:
a.
False positives: The test gives a positive result, even if you are not infected. This happens only
rarely and is more common in persons who have not engaged in high-risk behavior. Retesting
should be done to help confirm the validity of a positive test.
b.
False negatives: The test gives a negative result, even though you are infected with HIV. This
happens most commonly in recently infected persons; it takes 4-12 weeks for a positive result to
develop after a person is infected.
PFSHIV Page 1 of 2
Effective 12/11

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