Slr Em Education - Informed Consent To Perform Hiv Testing Template (Page 3 of 3) in pdf

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Informed Consent

NEW YORK STATE DEPARTMENT OF HEALTH

to Perform HIV Testing

AIDS Institute

My health care provider has answered any questions I have regarding

Part

HIV testing and has given me written information with the following

details about HIV testing:

• HIV is the virus that causes AIDS.

• The only way to know if you have HIV is to be tested.

• HIV testing is important for your health, especially for pregnant women.

• HIV testing is voluntary. Consent can be withdrawn at any time.

• Several testing options are available, including anonymous and conﬁdential.

• State law protects the conﬁdentiality of test results and also protects test subjects

from discrimination based on HIV status.

• My health care provider will talk with me about notifying my sex or

needle-sharing partners of possible exposure, if I test positive.

I agree to testing for the diagnosis of HIV infection. If I am found to have HIV, I agree to

additional testing which may occur on the sample I provide today to determine the best

treatment for me and to help guide HIV prevention programs. I also agree to future tests

to guide my treatment. I understand that I can withdraw my consent for future tests at

any time.

For pregnant women only:

In addition to the testing described above, I authorize my health care provider to

repeat HIV diagnostic testing later in this pregnancy. I understand that my health

care provider will discuss this testing with me before the test is repeated and will

provide me with the test results. The consent to repeat diagnostic testing is limited

to the course of my current pregnancy and can be withdrawn at any time.

Signature:

Date:

(Test subject or legally authorized representative)

If legal representative, indicate relationship to subject:

Printed Name:

Medical Record #:

Except for expedited HIV testing on labor units, this form replaces other HIV testing consent forms

as of June 1, 2005.

NOTE: this form is intended to be used in conjunction with DOH-2556i, Part A.

DOH-2556 (5/05)

Slr Em Education - Informed Consent To Perform Hiv Testing Template Page 3