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Required HIV Related Consent and Authorization Forms

HIV-Specific Model Consent Form

Informed Consent to Perform HIV Testing

"Informed Consent to Perform a Confidential HIV Test and Authorization for Release of HIV-related Information for Purposes of Providing Post-exposure Care to a Health Care Worker Exposed to a Patient's Blood or Body Fluids" is discontinued. Please see document below for more information.

Note: Spanish version is in revision. Please print and use 2556ES and 2557ES instead of 4054S.

Authorization for Release of Health Information and Confidential HIV Related Information

Requests for information in an alternate format can be made by sending an e-mail note to hivct@health.state.ny.us

Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS Related Information

This form, DOH-5032, was created to facilitate sharing of substance use, mental health and HIV/AIDS information. This form is somewhat like the "Authorization for Release of Medical Information and Confidential HIV Related Information" (DOH-2557), but would fulfill a need to share information within facilities in which different teams handle substance use, mental health and HIV/AIDS-related issues. In addition, the DOH-5032 would fulfill a need to share information between facilities and providers that care for the same patient. Like the DOH-2557, the DOH-5032 is intended to encourage multiple providers to discuss a single individual's care among and between themselves to facilitate coordinated and comprehensive treatment. Although the new form (DOH-5032) may be used in place of DOH-2557, it is not intended to replace any forms currently available.

Consent for Expedited HIV Testing in the Delivery Setting (DOH 4158)

The consent form for expedited testing in the delivery system has been replaced by the general consent form for HIV testing along with a copy of the "Key Messages For Pregnant Women About HIV"

Complaint Report for Alleged Violation of Article 27F