ACORD 783 Instructions


Section Name Field Name Field and/or Section Description
HIV Antibody/Antigen Consent and Testing Form, ACORD 783, should be signed by the insured or proposed insured in order to authorize HIV screening to occur. This form may not be used in AZ, CA, DC, FL, GA, MA, ME, MI, NH, NY, OH, OR, TX, VT, WA, WI or
WV.
TITLE ACORD 783 (2008/01) HIV Antibody/Antigen Consent and Testing Form IMPORTANT: This form is not filed with any regulator in any jurisdiction. This form cannot become part of aninsurance policy.
IDENTIFICATION SECTION Name of Requestor Name of Requestor must be inserted before this form is used.
Proposed Insured Name (Please
HIV CONSENT Print) Full name of the proposed insured. Please print if handwritten.
HIV CONSENT Date of Birth Indicate the date of birth of the proposed insured in MM/DD/YYYY format.
HIV CONSENT State of Residence Indicate the state of residence of the proposed insured.
HIV CONSENT Signature of Proposed Insured Proposed Insured must sign and date the form.
Signature of Person Obtaining
HIV CONSENT Consent Person obtaining consent must sign the form.
Name of Person Obtaining
HIV CONSENT Consent (Please Print) Full name of the person obtaining consent. Please print if handwritten.
DESIGNATED PHYSICIAN First Name First name of the designated physician.
DESIGNATED PHYSICIAN Middle Name Middle name of the designated physician.
DESIGNATED PHYSICIAN Last Name Last name of the designated physician.
DESIGNATED PHYSICIAN Address (No P.O. Box) Line 1 Indicate the address of the designated physician. Do not use P.O. Box number.
DESIGNATED PHYSICIAN Line 2 Address – Line 2.
DESIGNATED PHYSICIAN City Indicate the city of the address.
DESIGNATED PHYSICIAN State State of the address.
DESIGNATED PHYSICIAN Zip Zip code, postal code, etc. (country dependent)
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.
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 Identification code assigned to the agency or brokerage firm by the insurance company
INFORMATION Agency Code receiving this form.
PROPOSED INSURED INFORMATION Social Security Number Social security number of proposed insured.
PROPOSED INSURED INFORMATION Drivers License Number 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.