New Hampshire Code of Administrative Rules
Ins - Commissioner, Insurance Department
Chapter Ins 1100 - CONFIDENTIALITY OF HIV TESTS
Appendix A

State of New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301

HIV Antibody Testing Consent Form

The insurance company to which you have applied may request a blood, urine or oral fluid sample from you for testing. One test will be to detect the presence of antibodies to the Human Immunodeficency Virus (HIV). HIV is the virus which causes Acquired Immune Deficiency Syndrome (AIDS). The New Hampshire Unfair Insurance Trade Practices Act (RSA 417) provides for an insurance company to test for the presence of an antibody or antigen to HIV only upon your written consent. The results of this test may determine your eligibility to acquire insurance. By signing this form you have consented to the HIV test and the reporting of the test results to the insurance company taking your application. Positive test results will not be disclosed except as authorized by you in writing. Negative and indeterminate (inconclusive) test results may be disclosed to reinsurers, contractually retained medical personnel and insurance affiliates or subsidiaries that are involved in necessary underwriting decisions regarding your application. The insurance company and any other party receiving the negative or indeterminate tests results will maintain the results of your HIV antibody test as confidential.

If your test results indicate the presence of antibodies to HIV or if your test results cannot be accurately determined, the insurance company will report a "nonspecific abnormality" to the Medical Information Bureau. The Medical Information Bureau contains the names and computerized medical records of insurance applicants nationally. The report will not identify you as having an abnormal HIV antibody test because many abnormalities are reported to the Bureau under the same classification.

The HIV antibody test is extremely accurate. However, in rare instances the test may be positive in persons who are not infected with the virus. Additionally, the test may occasionally be negative in persons who are infected with HIV (a false negative). If your HIV antibody test is positive, it does not mean that you have AIDS. A positive test indicates that you have been infected with HIV. It also means that HIV is present in your body fluids (such as blood, semen, vaginal secretions) and that you could infect other people through sexual contact, by sharing intravenous needles, by having a baby, or by donating blood, semen or body organs. Persons who have a positive HIV antibody test should see a physician as soon as possible. A negative test result indicates that no antibodies to the HIV virus were found. Absence of HIV antibodies does not mean that you have not been infected with the virus. Nor does absence of HIV antibodies mean that you are immune to the virus.

Public health authorities urge that everyone become educated about how to protect themselves from HIV infection. If you have questions, please consult your own physician or contact the Centers for Disease Control and Prevention at 1-800-232-4636 or visit their website at http://www.cdc.gov/hiv/default.html/.

The insurance company will notify you if your test results are positive or if your results cannot be accurately determined. At your request, the company will also send your results to a physician or other person. You should request that your results be sent to your private physician so that he/she can interpret them for you. In the event of a positive or indeterminate test result, I authorize disclosure to the following physician or other person or entity:

_______________________________________________________________________________________

Name of Physician or other person/entity

_______________________________________________________________________________________

Street Address

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City State ZIP

Informed Consent

I have read and understand this information. I voluntarily consent to provide a sample of my blood, urine or oral fluid, the testing of that blood, urine or oral fluid and the disclosure of the test results as described above.

______________________________ ___________________________________

Proposed Insured Date of birth

______________________________ __________________ _________________

Signature of Proposed Insured Date Signed State of Residence

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Signature of Witness"