| 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. |