Slr Em Education - Informed Consent To Perform Hiv Testing Template

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Important Phone Numbers
NEW YORK STATE DEPARTMENT OF HEALTH
AIDS Institute
Informed Consent
New York State HIV/AIDS Hotlines (toll-free)
Call the Hotlines for information about HIV and AIDS and to find HIV testing sites
to Perform HIV Testing
• 1-800-541-AIDS (2437) • English
• 1-800-233-SIDA (7432) • Spanish
New York State TTY/TTD HIV/AIDS Information Line
• 1-212-925-9560
HIV testing is voluntary. Consent can be with-
Voice callers use the NY relay:
• 711 or 1-800-421-1220 and ask the operator for: 1-212-925-9560
drawn at any time by informing your provider.
Please read Parts A and B of this form, and sign
New York State HIV/AIDS Counseling Hotline
at the bottom of Part B, if you understand the
• 1-800-872-2777
following information and want HIV testing.
NYSDOH Anonymous HIV Counseling and Testing Program
For HIV information, referrals, or information on how to get a free, anonymous HIV test,
call the Anonymous HIV Counseling and Testing Programs.
HIV infection is a serious health concern.
• Albany Region 1-800-962-5065
The New York State Department of Health
• Buffalo Region 1-800-962-5064
recommends HIV testing. For pregnant women,
• Nassau Region 1-800-462-6785
the Department recommends HIV testing early in
• New Rochelle Region 1-800-828-0064
• Queens Region 1-800-462-6785
pregnancy and again late in pregnancy.
• Rochester Region 1-800-962-5063
• Suffolk Region 1-800-462-6786
• Syracuse Region 1-800-562-9423
NYCDOHMH HIV/AIDS Hotline: 1-800-TALK-HIV (1-800-825-5448)
New York State PartNer Assistance Program: 1-800-541-AIDS
New York City Contact Notification Assistance Program: 1-212-693-1419
Confidentiality
• New York State Confidentiality Hotline 1-800-962-5065
Except for expedited HIV testing on labor
Part
units, this form replaces other HIV testing
• Legal Action Center 1-212-243-1313 or 1-800–223-4044
A
consent forms as of June 1, 2005.
Human Rights/Discrimination
NOTE: this form is intended to be used in
conjunction with DOH-2556, Part B.
• New York State Division of Human Rights 1-800-523-2437
• New York City Commission on Human Rights 1-212-306-7500
DOH-2556i (6/05) page 4 of 4
DOH-2556i (6/05) page 1 of 4

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