North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-03 - Regulation of Insurance Companies › Chapter 45-03-11 - Notice, Consent, and Disclosure for Testing of Blood or Other Body Fluids › Section 45-03-11-03 - Prescribed form of informed consent

Current through Supplement No. 393, July, 2024
Any insurance company, health maintenance organization,
				  fraternal benefit society, benevolent society, or nonprofit health service
				  corporation which subjects an applicant for insurance coverage to a test for
				  the presence of an antibody or antigen to the human immunodeficiency virus
				  under section
				  45-03-11-02 shall provide the
				  applicant with an informed consent form and shall obtain the applicant's
				  signature on the form. The form must contain at least the following language
				  printed in type no smaller than ten point, and must take substantially the
				  following form:
EXAMINER ______________ INSURER ______________
ADDRESS ______________ ADDRESS ______________
NOTICE AND CONSENT FOR BLOOD (OR OTHER BODY FLUID) TESTING
				  AND DISCLOSURE WHICH MAY INCLUDE AIDS VIRUS (HIV) ANTIBODY/ANTIGEN TESTING
To determine your insurability, the Insurer named above (the
				  Insurer) has requested that you provide a sample of a body fluid for testing
				  and analysis. All tests will be performed by a licensed laboratory.
Tests may be performed to determine the presence of
				  antibodies or antigens to the Human Immunodeficiency Virus (HIV), also known as
				  the AIDS virus. Other tests which may be performed include determinations of
				  blood cholesterol and related lipids (fats) and screening for liver or kidney
				  disorders, diabetes, and immune disorders.
CONFIDENTIALITY
All test results will be treated confidentially. The results
				  of tests will be reported by the laboratory to the Insurer identified on this
				  form. 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 to whom
				  disclosure is reasonably necessary in the ordinary course of business to carry
				  out the purpose for which that disclosure is authorized. 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 nonspecific test
				  abnormality. If your HIV test is normal, no report will be made about it to the
				  MIB, Inc. Other test results may be reported to the MIB, Inc., in a more
				  specific manner. The organizations described in this paragraph may maintain the
				  test results in a file or data bank. There may be other disclosure of test
				  results as permitted by law or authorized by you.
NOTIFICATION OF RESULTS
If your HIV test results are normal, no routine notification
				  will be sent to you. If you are a resident of North Dakota and your HIV test is
				  other than normal, the Insurer will disclose test results to the North Dakota
				  Department of Health and Consolidated Laboratories as required by law. If the
				  HIV test results are other than normal, the North Dakota Department of Health
				  and Consolidated Laboratories will contact you.
SIGNIFICANCE OF POSITIVE TEST RESULTS AND AFFECT
				  ON APPLICATION FOR INSURANCE
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.
I have read and I understand this Notice of Consent for
				  Blood (or Other Body Fluid) Testing and Disclosure which may include HIV
				  antibody/antigen testing. I voluntarily consent to the testing of my blood or
				  other body fluids 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 (print) Date of Birth
_____________________________ _________ ____________________
Signature of Proposed Insured Date State of Residence or
				  Parent/Guardian
General Authority: NDCC 28-32-02
Law Implemented: NDCC
					 26.1-30-19