West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27 - AIDS Regulations › Appendix A

Current through Register Vol. XLI, No. 28, July 12, 2024
Examiner_____________________Insured___________________________________________
Address_____________________Address
				  _______________________________________
NOTICE AND CONSENT FOR BLOOD, URINE, OR ORAL FLUID
				  TESTING
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 your blood, urine, or oral
				  fluids 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. 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. This series of tests is extremely reliable.
				  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.
All test 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 reinsurers, employees,
				  or contractors. 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 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 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 you
				  desire, you have the right to request a complete list of the parties to whom
				  the insurer has released test information.
You should also be aware that the person who performs the
				  blood, urine or oral fluid testing is subject to W. Va. Code
				  §§
									16-3C-3 and 16-3C-4 which authorize that they may disclose test
				  results to certain limited individuals under certain limited circumstances
				  [these relate primarily to (1) persons you authorize to see the test results,
				  (2) health care providers who may come into contact with you or specimens
				  obtained from you, (3) the United States centers for disease control, (4) a
				  court order to release the results, and (5) identified sex partners and persons
				  sharing needles.] These persons are required by W. Va. Code §§
									16-3C-3
				  and 16-3C-4 to keep test information confidential.
You may direct that test results be disclosed directly to you
				  or if you prefer to your personal physician or other health care professional.
				  It is strongly suggested that you designate a physician or health care
				  professional to receive your test results so that they may properly explain the
				  results to 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 also contact you if there are other abnormal
				  test results which, in the Insurer's opinion, are significant. If you have not
				  already indicated one, the Insurer may ask you at that time 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 abnormalities discovered in the body fluid sample tested for the
				  presence of HIV 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 wish my test results to be released to:
(Check Please)
_____Myself only.
_____My physician, health care provider, or other person
				  indicated below.
_____Both myself and my physician, health care provider or
				  other person indicated below.
Physician, Health Care Provider, or other person.
Name:___________________________
Address:__________________________
_________________________________
I have read and I understand this Notice and Consent For
				  Blood, Urine or Oral Fluid Testing Which May Include AIDS Virus HIV
				  Antibody/Antigen Testing. I voluntarily consent to give a urine or oral fluid
				  specimen and/or to the withdrawal of blood from me, the testing of that urine
				  and/or blood or oral fluid, and the disclosure of the test results as
				  described.
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 Date State of Residence or
				  Parent/Guardian
THIS AUTHORIZATION EXPIRES AFTER 60
				  DAYS