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I have been offered the blood test for detection of
antibodies to the Human Immunodeficiency Virus (HIV) performed by an outside
laboratory. HIV is the causative agent of Acquired Immune Deficiency Syndrome
(AIDS).
I understand that this test may not be conclusive because a
positive result means additional tests may be needed and a negative result does
not necessarily eliminate consideration of AIDS. I have also been informed that
the results of this blood test will only be released to those health care
personnel and insurance companies providing medical care and coverage to me as
allowed by federal and state law. I understand that these test results will be
a part of my medical record and will be released if I have signed an
authorization for release of medical information.
I understand that not
all health insurance plans will pay for HIV testing. Should my insurance
company decline coverage I understand that I will be expected to pay for it
myself.
I have read the "Important Information on the HIV Antibody
Test" at the bottom of this form and have had the opportunity to ask any
questions I have regarding this test.
1. I hereby give my consent
for the performance of the HIV blood test and to the release of results as
outlined above.
2. I decline the opportunity for the HIV blood test
at this time.
3. The patient is a minor ________ years of age or
is unable to sign because:
___________________________________________________________________________
I accept ________decline ________the offer of the HlV blood test.
(Closest relative or
guardian) |
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(Date) |
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This blood test checks for the presence of antibodies
to the Human Immunodeficiency Virus (HIV) which causes AIDS. A positive result
could mean you have been exposed to the virus, but more testing would be needed
for confirmation. A true positive result does not mean you have AIDS, but it
could develop in the future. It also means you could pass the virus on to
others and therefore should not have unprotected sex or share injection needles
with anyone.
A negative result means that no antibodies to HIV were
detected in your blood. This result could mean you have never been exposed to
the virus, but you also could have been infected in the very recent past and it
is too soon for antibodies to be produced yet. A negative result does
not mean that you are immune to HIV, and therefore you still need to
follow all precautions regarding exposure to blood and body fluids through
unprotected sex, dirty needles, etc.
HIV testing is especially
important in pregnancy. If a pregnant woman is HIV positive, she has up to a
30% chance of infecting her unborn baby before or during birth, or afterwards
through breastfeeding. If this situation is known, however, and she takes
certain antiviral drugs during pregnancy, her baby has only an 8 % chance of
becoming infected. Although most experts strongly recommend HIV testing in
pregnancy, it is not included in routine obstetrical panels because federal law
requires written consent of the patient to perform the test.
Instructions:
1. Print this form, then fax or mail it.
2. Fax: (919)781-9247
3. Mail Address:
North Raleigh
11001 Durant Road
Suite 100
Raleigh, NC 27614
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