Connecticut Administrative Code › Title 19a - Public Health and Well-being › 586 - Informed Consent for an HIV-Related Test › Section 19a-586-3 - Standardized informed consent form

Current through July 10, 2024
The standard form to be used by insurers in obtaining
				applicants' informed consent pursuant to Sec.
				19a-586-2,
				which in the case of use by a health care center as defined in Sec.
				38a-175
				of the General Statutes, all references to "insurer" shall be changed to
				"health care center," is as follows:
NOTICE AND CONSENT FORM FOR AIDS VIRUS (HIV) ANTIBODY/ANTIGEN
				TESTING
Insurer: (Name and Address) Examiner: (Name and Address)
Acquired Immunodeficiency Syndrome (AIDS) is a life-threatening
				disorder of the immune system. It is caused by a virus called Human
				Immunodeficiency Virus (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 determine your insurability, the insurer named above (the
				Insurer) has requested that you provide a sample of your blood for testing and
				analysis. All tests will be performed by a licensed laboratory.
Unless precluded by law, tests will be performed to determine
				the presence of HIV antibodies or antigens. The HIV antibody test that we
				perform is actually a series of tests done by a medically accepted procedure.
				The HIV antigen test directly identifies AIDS viral particles. These tests are
				extremely reliable. Should you desire more information about the test of HIV
				infection before providing a blood sample, you may wish to consult with your
				physician or your local health department. If you are at high risk of HIV
				infection, you may want to be counseled and tested by your physician or at a
				free/low cost local test site. Your local health department can provide you
				with information as to the location of these sites.
All tests results will be treated confidentially. They will be
				reported by the laboratory to the insurer. When necessary for business reasons
				in connection with insurance you have or have applied for with the Insurer, the
				Insurer may disclose test results to others such as its affiliates, reinsurers,
				employees or contractors, but not to agents and brokers.
If the Insurer is a member of the Medical Information Bureau
				(MIB, Inc.), and if the test results for HIV antibodies/antigens are other than
				normal, the Insurer will report to the MIB, Inc. a generic code which signifies
				only a non-specific blood test abnormality. If your HIV test is normal, no
				report will be made about it to the MIB, Inc.
The organizations described in the last two paragraphs may
				maintain the test results in a file or data bank. There will be no other
				disclosure of test results or even that the tests have been done except as may
				be required or permitted by law or as authorized by you.
If your HIV test results are normal, no routine notification
				will be sent to you. If the HIV test results are other than normal, the Insurer
				will contact you. The Insurer may ask you for the name of a physician or other
				health care provider to whom you may authorize disclosure and with whom you may
				wish to discuss the results.
Positive HIV antibody/antigen test results do not mean that you
				have AIDS, but that you are at significantly increased risk of developing AIDS
				or AIDS-related conditions. Federal authorities say that persons who are HIV
				antibody/antigen positive should be considered infected with the AIDS virus and
				capable of infecting others.
Positive HIV antibody or antigen test results or other
				significant blood abnormalities will adversely affect your application for
				insurance. This means that your application may be declined, that an increased
				premium may be charged, or that other policy changes may be necessary.
You are urged, at this time, to designate the physician or
				other health care provider to whom the HIV test results may be disclosed by the
				Insurer in the event the results are other than normal.
I authorize the disclosure of any HIV test results which are
				other than normal to the following physician or health care provider:
Name ____________ Address ____________
_______________
Zip Code___________
I have read and understand this Notice of Consent for AIDS
				Virus (HIV) Antibody/Antigen Testing. I voluntarily consent to the withdrawal
				of blood from me by needle, the testing of that blood, and the disclosure of
				the test results as described above.
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.
____________ _______________
Proposed Insured Date of Birth
____________ _______________
Signature of Proposed Insured or Parent/Guardian State of
				Residence
_________________________________
Date