Hiv Consent Form - Pro Financial Services (Page 2 of 2) in pdf

HIV Consent Form

Side Effects: A positive test result may cause you significant anxiety. A positive test may result in

uninsurability for life, health, or disability insurance policies you may apply for in the future. Although

prohibited by law, discrimination in housing, employment or public accomodations may result if your

test results were to become known to others. A negative result may create a false sense of security.

Disclosure of Results: All final positive test results will be disclosed to you. You may choose to have

information about your HIV test results communicated to you through your physician, through the

county health department, or directly. Please indicate below:

My physician: ______________________________

Address:

______________________________

The county health department

Me directly

If your test results are negative, no routine notification will be sent to you.

Confidentiality: Like all medical information, HIV test results are confidential. An insurer, insurance

agent or insurance-support organization is required to maintain the confidentiality of HIV test results.

However, certain disclosures of your test results may occur however, including those authorized by

consent forms that you may have signed as part of your overall application. Your test results may be

provided to affiliates, reinsurers, employees and contractors of the insurer in relation to the

underwriting of the insurance application. In addition, a positive result from a blood or oral specimen

test may be reported to the Medical Information Bureau, a national insurance data bank, as a non- specific

abnormality determined by the testing of blood or oral specimen.

Prevention: Persons who have had a history of high-risk behavior should change these behaviors to

prevent getting or giving AIDS, regardless of whether they are tested. Specific important changes in

behavior include safe sex practices (including condom use for sexual contact with someone other than a

long-term monogamous partner) and not sharing needles.

Consent

I have read and I understand this Notice and Consent for AIDS-Related Blood Testing. I voluntarily consent to

the withdrawl of blood from me, the testing of that blood, and the disclosure of the test results as described above.

This consent suthorization is limited to 6 months from the date it is signed. If the test is not performed within six

months or restesting is necessary after 6 months, a new consent authorization form must be obtained.

I understand that I have the right to request and receive a copy of this authorization. A photocopy of this form

will be as valid as the original.

_________________________________

Name of Covered Individual

_________________________________

Address

Date Signed

Hiv Consent Form - Pro Financial Services Page 2