Hiv Testing Authorization For Release
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1HIV Testing
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It is universally recommended that all pregnant women be tested for HIV, preferably at the 1
prenatal visit. HIV testing can only be
done with a patient’s consent. If a mother declines HIV testing during pregnancy, New York State mandates that the infant be tested
at birth using a “rapid test,” without requiring maternal consent. By signing below, you agree to be tested for HIV.
Authorization for Release of Health Information and Confidential HIV- Related Information*
This form authorizes release of health information including HIV-related information. Confidential HIV-related information is any
information indicating that a person has had an HIV-related test, or has HIV infection, HIV-related illness or AIDS, or any information
that could indicate a person has been potentially exposed to HIV.
Under New York State Law HIV-related information can only be given to people you allow to have it by signing a written release.
This information may also be released to the following: health providers caring for you or your exposed child; health officials when
required by law; insurers to permit payment; persons involved in foster care or adoption; official correctional, probation and parole
staff, emergency or health care staff who are accidently exposed to your blood; or by special court order. For more information
about HIV confidentiality, call the NYS Dept of Health HIV Confidentiality Hotline at 1-800-962-5065; for more information regarding
federal privacy protection, call the Office of Civil Rights at 1-800-368-1019.
By signing below, health and HIV-related information can be given to the hospital(s) listed. Upon your request, you can obtain a
copy of this form.
nd
Facility disclosing information:
Lexington OB/GYN 145 East 32
St. NY, NY 10016
Information to be released:
All pregnancy records, including HIV-related information.
Reason for release of information:
Coordination of obstetrical care with hospital.
Time period during which release is authorized:
Duration of obstetrical care.
Exceptions to the right to revoke consent:
Information required for care of the fetus or newborn.
Consequences of failing to consent to disclosure:
Coordination of care and services will be limited, tests will
need to be repeated, HIV testing will be required in the
hospital for you and/or your newborn.
Facility to be given health and/or HIV-related information:
Mount Sinai Hospital 1176 Fifth Ave. NY, NY 10029
or other hospital in an emergency situation.
The law protects you from HIV-related discrimination in housing, employment, health care and other services. For more
information, call the New York City Commission on Human Rights at (212)306-7500 or NYS Division of Human Rights at 1-888-392-
3644.
My questions about this form have been answered. I know that I do not have to allow release of my health and/or HIV-related
information, and that I can change my mind at any time and revoke my authorization by writing the facility obtaining this release. I
authorize the facility noted above to test me for HIV, and to release my health and HIV-related information to the organization
listed.
Signature ___________________________________________________________________ Date ___________________________
Lexington OB/GYN (rev 5/14)
*Adapted from NYS Department of Health form DOH 2557 (2/11)
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