Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 490 - ACQUIRED IMMUNE DEFICIENCY SYNDROME AND MEDICAL AND LIFESTYLE STANDARDS RULE › Attachment 031-490-A - HIV TEST INFORMED CONSENT FORM

Current through 2024-29, July 17, 2024
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.
________________________________ _________________
Name of Proposed Insured (Please Print) Birth Date
________________________________ _________________
Signature of Proposed Insured Date
________________________________
State of Residence
________________________________ _________________
Signature of Person Obtaining Consent Date