Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix A

Current through June 24, 2024
[Insurer name and address]
WISCONSIN NOTICE AND CONSENT FOR HUMAN IMMUNODEFICIENCY
				TESTING
REQUEST FOR CONSENT FOR TESTING
To evaluate your insurability, ( insurer name ) (Insurer)
				requests that you be tested to determine the presence of human immunodeficiency
				virus (HIV) antibody or antigens. By signing and dating this form, you agree
				that this test may be done and that underwriting decisions may be based on the
				test results. A licensed laboratory will perform one or more tests approved by
				the Wisconsin Commissioner of Insurance.
PRETESTING CONSIDERATION
Many public health organizations recommend that, if you have
				any reason to believe you may have been exposed to HIV, you become informed
				about the implications of the test before being tested. You may obtain
				information about HIV and counseling from a private health care provider, a
				public health clinic, or one of the AIDS service organizations on the attached
				list. You may also wish to obtain an HIV test from an anonymous counseling and
				testing site before signing this consent form. The Insurer is prohibited from
				asking you whether you have been tested at an anonymous counseling and testing
				site and from obtaining the results of such a test.
For further
				information on these options, contact the Wisconsin AIDSline at
				1-800-334-2437.
MEANING OF POSITIVE TEST RESULTS
This is not a test for AIDS. It is a test for HIV and shows
				whether you have been infected by the virus. A positive test result may have an
				effect on your ability to obtain insurance. A positive test result does not
				mean that you have AIDS, but it does mean that you are at a seriously increased
				risk of developing problems with your immune system. HIV tests are very
				sensitive and specific. Errors are rare but they can occur. If your test result
				is positive, you may wish to consider further independent testing from your
				physician, a public health clinic, or an anonymous counseling and testing
				site.
HIV testing may be arranged by calling the Wisconsin AIDSline at
				1-800-334-2437.
NOTIFICATION OF TEST RESULTS
If your HIV test result is negative, no routine notification
				will be sent to you. If your HIV test result is other than normal, the Insurer
				will contact you and ask 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 test results.
DISCLOSURE OF TEST RESULTS
All test results will be treated confidentially. The laboratory
				that does the testing will report the result to the Insurer. If necessary to
				process your application, the Insurer may disclose your test result to another
				entity such as a contractor, affiliate, or reinsurer. If your HIV test is
				positive, the Insurer may report it to the Medical Information Bureau (MIB,
				Inc.), as described in the notice given to you at the time of application. If
				your HIV test is negative, no report about it will be made to the MIB, Inc. The
				organizations described in this paragraph may maintain the test results in a
				file or data bank. These organizations may not disclose the fact that the test
				has been done or the result of the test except as permitted by law or
				authorized in writing by you.
CONSENT
I have read and I understand this notice and consent for HIV
				testing. I voluntarily consent to this testing and the disclosure of the test
				result as described above. A photocopy or facsimile of this form will be as
				valid as the original.
_______________________________/____________
Signature of Proposed Insured or Parent,
Guardian, or Health Care Agent/Date
___________________________________________
Name of Proposed Insured (Print)
___________________________________________
Date of Birth
___________________________________________
Address
___________________________________________
City, State, and Zip Code