Consent Form for HIV Blood Test

Before proceeding we must inform you that we cannot provide legal advice to individual TMA members because Texas prohibits the "corporate practice of law" (Texas Government Code Ann. '81.101). In addition, the State Bar of Texas has ruled that corporate-employed attorneys may not provide legal services to customers of the corporation if a corporation receives fees that are, to any extent, compensation to the corporation for the attorney's legal services to the customers. To do so is a prohibited form of "fee-splitting" (Ethics Opinion 498, January 1995). The fact that TMA is a non-profit corporation does not seem to change the conclusion. However, we can provide general legal information about this topic. Because your facts may vary, you should contact your own retained counsel for true legal advice and representation.

Consent for HIV Blood Test

Acknowledgment of Counseling

Consent to Release Test Results

Consent for HIV Testing  

 

Consent for HIV Blood Test  

I, __________________________, voluntarily consent to be tested in order to detect whether or not I have had exposure to the human immunodeficiency virus (HIV), which is the probably causative agent of acquired immune deficiency syndrome (AIDS), by ( specific name of physician ordering test ).  I realize that I can refuse the test.  I realize that the test will be performed by withdrawing blood and using a substance to test the blood.  I know that my test results are confidential under Texas law, and that unless I specify otherwise, the test result will be released to the physician who ordered the test, and to other persons only as required by law.

Patient:  ___________________________

Print Name: ________________________

Witness: ___________________________

Date: ______________________________

 

Acknowledgment of Counseling  

I understand that I have tested positive for the human immunodeficiency virus (HIV), which is the probable causative agent of acquired immune deficiency syndrome (AIDS).  I acknowledge that, after receiving my test result, I received immediate face-to-face counseling from ( specify name of person providing counseling ) about (1) the meaning of the test result, (2) the possible need for additional confirmatory testing, (3) measures to prevent the transmission of HIV, (4) the availability of appropriate health care services, including mental health care, and appropriate social and support services in the area of my residence, (5) the benefits of partner notification, and (6) the availability of the Texas Department of State Health Services Partner Notification Program.

Patient:  ___________________________

Print Name: ________________________

Witness: ___________________________

Date: ______________________________

 

Consent to Release Test Result  

I voluntarily authorize the release and disclosure of my test result for the human immunodeficiency virus (HIV), which is the probable causative agent of acquired immune deficiency syndrome (AIDS), to ( specify the person or class of persons to whom the test result may be disclosed ).  The purpose for the release of this test result is: ( specify purpose for release ).  I understand that no additional release of this information will be made without my express written authorization

Patient:  ___________________________

Print Name: ________________________

Witness: ___________________________

Date: ______________________________

 

A PERSON LEGALLY AUTHORIZED TO CONSENT TO THE TEST ON THE PATIENT'S BEHALF MAY SIGN FOR THE PATIENT IF THE PATIENT IS UNABLE TO DO SO OR IS UNDER 18 YEARS OF AGE.  THIS FORM COMPLIES WITH THE REQUIREMENTS OF THE COMMUNICABLE DISEASE PREVENTION AND CONTROL ACT, TEXAS HEALTH AND SAFETY CODE, CHAPTER 81.

Prepared by: TMA Office of the General Counsel  

NOTICE: The Office of the General Counsel of the Texas Medical Association provides this information with the express understanding that 1) no attorney-client relationship exists, 2) neither TMA nor its attorneys are engaged in providing legal advice and 3) that the information is of a general character. You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be sought.  

Last Updated On

August 02, 2016

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