ACORd 757OH Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 757 OH (2009/02) Ohio HIV Antibody / Antigen Consent and Testing Form ACORD 757 OH, Ohio HIV Antibody / Antigen Consent and Testing Form, needs to be signed by the insured or proposed insured in order to authorize HIV screening to occur.
IDENTIFICATION SECTION Name and Address of Insurance Company Name of Insurance Company must be inserted before this form is used. Use the actual name of the company. Do not use group names.
NOTIFICATION OF A POSITIVE TEST RESULT Send the result to applicant check box In the event of a positive test result, the applicant may select, by checking the applicable box, to have the result sent to themselves.
NOTIFICATION OF A POSITIVE TEST RESULT Address (Applicant) Indicate the address of the applicant. Do not use P.O. Box number.
NOTIFICATION OF A POSITIVE TEST RESULT Send the result to another person check box In the event of a positive test result, the applicant may select, by checking the applicable box, to have the result sent to another person.
NOTIFICATION OF A POSITIVE TEST RESULT Name (Another Person) Indicate the name of the person to whom you wish the test result sent.
NOTIFICATION OF A POSITIVE TEST RESULT Another Person Address Indicate the address of the person to whom you wish the test result sent. Do not use P.O. Box number.
NOTIFICATION OF A POSITIVE TEST RESULT Send the result to a physician or health careprovider check box In the event of a positive test result, the applicant may select, by checking the applicable box, to have the result sent to a physician or health care provider.
NOTIFICATION OF A POSITIVE TEST RESULT Physician’s Name Indicate the name of the physician or health care provider to whom you wish the test result sent.
NOTIFICATION OF A POSITIVE TEST RESULT Physician’s Address Indicate the address of the physician or health care provider to whom you wish the test result sent. Do not use P.O. Box number.
AUTHORIZATION Name of Applicant Full name of the applicant. Please print if handwritten.
AUTHORIZATION Signature of Applicant Applicant must sign and date the form.
AUTHORIZATION Signature of Legal Guardian, if Any Legal Guardian must sign and date the form, if applicable.
AUTHORIZATION Signature of Person Obtaining Consent Person obtaining consent must sign the form.
PROPOSED INSURED INFORMATION This section to be completed by the examiner.
PROPOSED INSURED INFORMATION Policy Number Number exactly as it appears on the policy, including prefix and suffix symbols.
PROPOSED INSURED INFORMATION Agency Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.
PROPOSED INSURED INFORMATION Social Security Number Social security number of proposed insured.

ACORD 757 OH (2009/02) 1 of 2 ACORD 757 OH (2009/02) 2 of 2

Section Name Field Name Field and/or Section Description
PROPOSED INSURED INFORMATION Drivers LicenseNumber Driver’s license number of proposed insured.
PROPOSED INSURED INFORMATION Number of Hours Since Last Food or Drink Indicate the number of hours since the proposed insured’s last food or drink.
PROPOSED INSURED INFORMATION Date and Time Specimen Collected Indicate the date (MM/DD/YYYY) and time (a.m. or p.m.) the specimen was collected.
PROPOSED INSURED INFORMATION Urine Temperature Indicate the temperature of the urine specimen.
PROPOSED INSURED INFORMATION Male/Female Check the appropriate box.
EXAMINER/COMPANY INFORMATION Examiner Name Indicate the full name of the examiner.
EXAMINER/COMPANY INFORMATION Examiner Company Name Indicate the name of the examiner’s company.