HIV Testing and Counseling Baseline & 3-Month Follow-up

Important Phone Numbers

NEW YORK STATE DEPARTMENT OF HEALTH
AIDS Institute

Informed Consent
to Perform HIV Testing

New York State HIV/AIDS Hotlines (toll-free)
Call the Hotlines for information about HIV and AIDS and to find HIV testing sites
• 1-800-541-AIDS (2437) • English
• 1-800-233-SIDA (7432) • Spanish
New York State TTY/TTD HIV/AIDS Information Line
• 1-212-925-9560
Voice callers use the NY relay:
• 711 or 1-800-421-1220 and ask the operator for: 1-212-925-9560

HIV testing is voluntary. Consent can be withdrawn at any time by informing your provider.
Please read Parts A and B of this form, and sign

New York State HIV/AIDS Counseling Hotline
• 1-800-872-2777

at the bottom of Part B, if you understand the
following information and want HIV testing.

NYSDOH Anonymous HIV Counseling and Testing Program
For HIV information, referrals, or information on how to get a free, anonymous HIV test,
call the Anonymous HIV Counseling and Testing Programs.
• Albany Region 1-800-962-5065
• Buffalo Region 1-800-962-5064
• Nassau Region 1-800-462-6785
• New Rochelle Region 1-800-828-0064
• Queens Region 1-800-462-6785
• Rochester Region 1-800-962-5063
• Suffolk Region 1-800-462-6786
• Syracuse Region 1-800-562-9423

HIV infection is a serious health concern.
The New York State Department of Health
recommends HIV testing. For pregnant women,
the Department recommends HIV testing early in
pregnancy and again late in pregnancy.

NYCDOHMH HIV/AIDS Hotline: 1-800-TALK-HIV (1-800-825-5448)
New York State PartNer Assistance Program: 1-800-541-AIDS
New York City Contact Notification Assistance Program: 1-212-693-1419
Confidentiality
• New York State Confidentiality Hotline 1-800-962-5065
• Legal Action Center 1-212-243-1313 or 1-800–223-4044

Except for expedited HIV testing on labor
units, this form replaces other HIV testing
consent forms as of June 1, 2005.

Human Rights/Discrimination
• New York State Division of Human Rights 1-800-523-2437
• New York City Commission on Human Rights 1-212-306-7500

NOTE: this form is intended to be used in
conjunction with DOH-2556, Part B.

DOH-2556i (6/05) page 4 of 4

DOH-2556i (6/05) page 1 of 4

Part

A

HIV is the virus that causes AIDS.

HIV testing is especially important for pregnant women.

• HIV is passed from one person to another during unprotected sex (vaginal, anal or oral
sex without a condom) with someone who has HIV.
• HIV is passed through contact with blood as in sharing needles (piercing, tattooing or
injecting drugs of any kind) or sharing works with a person who has HIV.

• An infected mother can pass HIV to her child during pregnancy or birth or through
breastfeeding.
• It is much better to know your HIV status before or early in pregnancy so you can make
important decisions about your own health and the health of your baby.
• If you are pregnant and have HIV, treatment is available for your own health and to
prevent passing HIV to your baby. If you have HIV and do not get treatment, the chance
of passing HIV to your baby is one in four. If you get treatment, your chance of passing
HIV to your baby is much lower.
• If you are not tested during pregnancy, your provider will recommend testing when you
are in labor. In all cases, your baby will be tested after birth. A positive test on your
baby means that you have HIV and your baby has been exposed to the virus.

The only way to know if you have HIV is to be tested.
• HIV tests are safe. They involve collecting one or more specimens (blood, oral fluid,
urine).
• Your counselor or doctor will explain your test result as well as any other tests you may
need.

Your HIV test today includes:
• A test to see if you have HIV infection (an antibody test or a test for the virus);
• If you are HIV positive, additional tests may include tests to:
• help your doctor decide the best treatment for you.
• help guide the health department with HIV prevention programs.

Several testing options are available.
• You can choose to have a confidential test where the result becomes part of your
medical record and can be given to your health care provider for HIV and other health
care services, or
• You can choose to have an anonymous test, which means that you don’t give your name
and no record is kept of the test result. If your anonymous test is HIV-positive, you can
choose to give your name later so you can get medical care more quickly.
• To get more information about options for testing and free or anonymous testing sites,
ask your counselor/doctor or call 1-800-541-AIDS.

HIV testing is important for your health.
• If your test result is negative, you can learn how to protect yourself from being infected
in the future.
• If your test result is positive:
• You can take steps to prevent passing the virus to others.
• You can receive treatment for HIV and learn about other ways to stay healthy. As
part of treatment, additional tests will be done to determine the best treatment for
you. These tests may include viral load and viral resistance tests.
DOH-2556i (6/05) page 2 of 4

If you test positive:
State law protects the confidentiality of your test results and also protects you from
discrimination based on your HIV status.
• In almost all cases, you will be asked to give written approval before your HIV test
result can be shared.
• Your HIV information can be released to health providers caring for you or your
exposed child; to health officials when required by law; to insurers to permit payment;
to persons involved in foster care or adoption; to official correctional, probation and
parole staff; to emergency or health care staff who are accidentally exposed to your
blood; or by special court order.
• The names of persons with HIV are reported to the State Health Department for tracking the epidemic and for planning services.
• The HIV Confidentiality Hotline at 1-800-962-5065 can answer your questions and help
with confidentiality problems.
• The New York State Division of Human Rights at 1-800-523-2437 can help if you think
you’ve been discriminated against based on your HIV status.
Your counselor/doctor will talk with you about notifying your sex or needle-sharing
partners of possible exposure to HIV.
• Your partners need to know that they may have been exposed to HIV so they can be
tested and get treated if they have HIV.
• If your health care provider knows the name of your spouse or other partner, he or she
must report the name to the health department.
• Health department counselors can help notify your partner(s) without ever telling them
your name.
• To ensure your safety, your counselor or doctor will ask you questions about the risk of
domestic violence for each partner to be notified.
• If there is any risk, the Health department will not notify partners right away and will
assist you in getting help.
DOH-2556i (6/05) page 3 of 4

NEW YORK STATE DEPARTMENT OF HEALTH
AIDS Institute

Informed Consent
to Perform HIV Testing

My health care provider has answered any questions I have regarding
HIV testing and has given me written information with the following
details about HIV testing:

Part

B

• HIV is the virus that causes AIDS.
• The only way to know if you have HIV is to be tested.
• HIV testing is important for your health, especially for pregnant women.
• HIV testing is voluntary. Consent can be withdrawn at any time.
• Several testing options are available, including anonymous and confidential.
• State law protects the confidentiality of test results and also protects test subjects
from discrimination based on HIV status.
• My health care provider will talk with me about notifying my sex or
needle-sharing partners of possible exposure, if I test positive.

I agree to testing for the diagnosis of HIV infection. If I am found to have HIV, I agree to
additional testing which may occur on the sample I provide today to determine the best
treatment for me and to help guide HIV prevention programs. I also agree to future tests
to guide my treatment. I understand that I can withdraw my consent for future tests at
any time.

For pregnant women only:
In addition to the testing described above, I authorize my health care provider to
repeat HIV diagnostic testing later in this pregnancy. I understand that my health
care provider will discuss this testing with me before the test is repeated and will
provide me with the test results. The consent to repeat diagnostic testing is limited
to the course of my current pregnancy and can be withdrawn at any time.
Signature:

Date:
(Test subject or legally authorized representative)

If legal representative, indicate relationship to subject:
Printed Name:
Medical Record #:
Except for expedited HIV testing on labor units, this form replaces other HIV testing consent forms
as of June 1, 2005.
NOTE: this form is intended to be used in conjunction with DOH-2556i, Part A.
DOH-2556 (5/05)