Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 42016 (Rev. 10/03)

STATE OF WISCONSIN s. 252.15 (2) and (5) 608 267-5287

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL HIV TEST RESULTS
All information recorded on this form is confidential and not shared without your consent except as provided by law. See reverse side of this form for a listing of persons who may receive confidential HIV test results without needing an authorization, as specified under Wisconsin statute 252.15(5)(a). Name of person whose HIV test results will be released: Name and address of organization that I am authorizing to release HIV test results:

Person(s) or organization(s) that I am authorizing to receive these HIV test results:

This authorization will expire on the following date or when the following event takes place: Date of expiration: Event: Reason for signing release of confidential HIV test results form:

I understand that, unless otherwise stated below, I am not required to sign this form and signing the form is not a condition of receiving treatment, payment, enrollment, or eligibility for benefits. Purpose for need of disclosure (if applicable): I can change my mind at any time and revoke this authorization in writing. The written revocation must be given to the person(s) that I authorized to release the test results. I understand that if I do revoke this authorization, it will not affect the uses and disclosures of test results that have already occurred based on my authorization. I understand that information used or disclosed based on this authorization may possibly be re-disclosed by the recipient and/or no longer be protected by Federal privacy standards. My questions about this two-sided form have been answered to my satisfaction. I also understand that if I sign this authorization, I will be provided a copy of this authorization. I authorize the person(s) and organization(s) that I have designated above to receive my HIV test results (or the test results of the person named above.)

SIGNATURE of Test Subject

Date Signed

SIGNATURE of Person Legally Authorized to Sign on Behalf of Test Subject

Date Signed

Print name of person legally authorized to sign on behalf of test subject

Relationship of person legally authorized to sign on behalf of test subject.

DPH 42016 (Rev. 10/03)

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Disclosure:

Wisconsin law requires that HIV test results can only be given to people who are authorized to have access to these results or in the limited circumstances specified in statute 252.15(5)(a).

The following are persons who may receive name-associated HIV test results under certain circumstances specified by Wisconsin statute 252.15(5)(a). The person tested; and if the person is incapacitated, the person designated as the agent in the health care power of attorney; The person's health care provider, including a health care provider who provides emergency care to the person tested; An agent or employee of the tested person's health care provider who provides patient care or handles specimens of body fluids or tissues or prepares or stores patient health care records; A blood bank, blood center or plasma center that subjects a person to a test; A health care provider who procures, processes, distributes or uses a human body part for the purpose of ensuring medical acceptability of the donated body part; The State Epidemiologist or his/her designee for the purpose of communicable disease investigation or control or epidemiological surveillance; A funeral director or to other persons who prepare a corpse for burial or other disposition; or to a person who performs or assists in an autopsy; Health care facility staff committees or accreditation or health care services review organizations for conducting program monitoring, evaluations and reviews; Under a court order; A person who conducts research, if the researcher :
· Is affiliated with the tested person's health care provider, and · Has obtained permission to perform the research from an

A person rendering emergency care to a victim if significantly exposed; A coroner or medical examiner or assistant if: § the HIV-infected status is relevant to the determination of cause of death, or § during direct investigation the coroner, medical examiner or appointed assistant is significantly exposed to the subject; A sheriff; jailer; keeper of a prison, jail or house of correction; for the purpose of assigning private cells; If the test results were positive and the tested patient is now deceased, persons known by the deceased patient's physician to have had sexual contact or shared intravenous drug equipment with that patient; A person who consents for testing an individual who is under 14 years of age, or declared incompetent by a court, or is unable to communicate because of a medical condition; An alleged victim or victim of sexual assault, the victim or alleged victim's parent or guardian and the victim or alleged victim's healthcare provider; To a person who is significantly exposed, as defined by state statute, through certain occupations; To a foster parent or treatment foster parent or the operator of a group home, child caring institution or correctional facility in which a child is placed. If the person is a prisoner, the prisoner's health care provider and medical and intake staff of the prison or jail.

institutional review board, and
· Provides written assurance that the information will not be

released and will not identify the person tested without informed consent;