Attachment 031-490-A - HIV TEST INFORMED CONSENT FORM

Current through 2022-14, April 6, 2022

Insurer: (Name and Address) Examiner: (Name and Address)

BACKGROUND

Acquired Immunodeficiency Syndrome (AIDS) is a life-threatening disorder of the immune system. It is caused by a virus called HIV. The virus is spread by sexual contact with an infected person, by exposure to infected blood (as in needle sharing during intravenous drug use or, rarely, as a result of a blood transfusion), or from an infected mother to her newborn infant.

To evaluate your eligibility for insurance or insurance benefits, it is requested that you provide a sample of your body fluid or other specimen for testing and analysis. One of the tests is to determine the presence of antibodies to the HIV virus. This test is actually a series of tests performed upon your body fluid or other specimen sample by a medically accepted procedure which is extremely reliable. The testing will be performed by a licensed laboratory.

DISCLOSURE OF TEST RESULTS

All test results will be treated confidentially. The results of the test will be reported to the insurer named above. The results also may be reported to its affiliates, reinsurer, or contractors in connection with insurance you have or for which you have applied.

In addition, if your HIV antibody test is abnormal (positive), the insurer may request an additional sample as necessary. If the insurer is a member of the Medical Information Bureau (MIB) and you choose to decline that request, the insurer will report to MIB a generic code which specifies only that a test has been ordered and not received. If the final test result for HIV antibodies is other than normal, a generic code signifying a nonspecific blood abnormality may be made known to the Medical Information Bureau (MIB) as described in the notice given you at the time of application. The MIB is a membership organization of life and health insurance companies which operates as an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or make a claim for benefits to such a company, the MIB, upon request, will supply the information in its file to that member. The fact that the test has been done and the results of the test will not be otherwise disclosed except as may be required by law or as authorized by you.

TEST RESULTS

Positive Test Results. While positive test results do not necessarily mean that you have AIDS, they do mean that you are at serious risk of developing AIDS or AIDS-related conditions. You may be infected with HIV and infectious to others. You should seek medical follow-up with your personal health care provider. The insurer will contact you for the name of the health care provider to whom you may want your test results disclosed.

Test Accuracy. HIV test results are not 100 percent accurate. Possible errors include:

(a) False positives: The test gives a positive result, even though you are not infected. This happens only rarely and is more common in persons who have not engaged in high risk behaviors. 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 is most likely to happen in recently infected persons; it takes at least 4 to 12 weeks for a positive test result to develop after a person is infected, and may take as long as 6 to 12 months.

RISKS FROM HAVING THE TESTS

A positive test result may cause you significant anxiety. It also will adversely affect your insurance application and may result in uninsurability for life, health, or disability insurance for which you may apply in the future.

YOU HAVE THE RIGHT TO ASK QUESTIONS (EITHER ORALLY OR IN WRITING) AND OBTAIN FURTHER INFORMATION

If you have any questions relating to AIDS, the HIV test and the consequences of being tested or not being tested, you are entitled to answers to those questions by the person offering the test or other knowledgeable person before you agree to testing.

OTHER SOURCES OF INFORMATION

For more information about AIDS and the HIV test, you may call the Maine Bureau of Health at (207) 287-3747. You may also call the Maine AIDS Hotline at 1-800-851-AIDS. (Insurers may at their option provide an additional reference to their corporate medical departments.)

I have read and I understand this Notice of AIDS Virus (HIV) Antibody Testing and Consent for Testing. For my information, I have been given written material about AIDS. I voluntarily consent to the withdrawal of body fluid or other specimen from me, the testing of my body fluid or other specimen for HIV antibodies, and the disclosure of the test results as described above.

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Name of Proposed Insured (Please Print) Birth Date

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Signature of Proposed Insured Date

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State of Residence

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Signature of Person Obtaining Consent Date

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