FAITH Enrollment Form

Would you like any assistance from TKO with any of these services?

Your health check is being provided by: The Knights & Orchids Society Inc. 17 Broad Street Selma, AL 36701​       INFORMED CONSENT TO PERFORM HIV TESTING HIV testing shows whether a person body is producing antibodies. HIV stands for human immunodeficiency virus. HIV is the virus that causes AIDS (acquired immunodeficiency syndrome). Before you receive an HIV antibody test (or STD/STI test), you must give your consent.     If you have any questions, feel free to ask them.  1.What is the HIV Antibody Test? It is a test that shows if you have antibodies that develops as a result of HIV in your body. A blood (fingerstick / venipuncture) or oral sample will be taken from you and be tested. If the first test shows that you have the antibodies, a different test will be done to make sure the first test was right. 2.What does it mean if the test is negative? A negative result doesn't necessarily mean that you don't have HIV. That's because of the window period—the time between when a person gets HIV and when a test can accurately detect it. The window period varies from person to person and is also different depending upon the type of HIV test. If you are at higher risk for HIV we suggest routine testing every three months. Please let us know if you would like to discuss other prevention options available to you at no cost. 3.What does it mean if the confirmatory test is positive? If you have a positive HIV test result, a follow-up test will be conducted. If the follow-up test is also positive, it means you are HIV-positive. AND THAT'S ABSOLUTELY OK! We have affirming doctors who are ready to care for you and our coordinators will be available to make sure you access the best possible care. We Keep Us Safe! 4. Do I have to take the test? No. Taking the test is up to you. In most cases, you can't be made to take the HIV antibody test. If you don't want the test, you can still get essential support services. If you want to take the test, you don’t have to let anyone know your test result. You don’t even have to tell anyone you've taken the test. 5. Do I have to tell anyone my test result? If you take the test, your result is private. Only the people listed on this form may have the result. If your test is positive, your sex and needle- sharing partners need to know. This is true for past and present partners. There is a special program that can help you tell your partners. If you are unable to tell partners yourself, they may be told, and your name won't be used. By signing this consent form you give permission to The Knights & Orchids Society to give your name to the Department of Public Health’s Partner Services staff, UAB Selma Family Medicine or the West Alabama Women's Center (WAWC) for the purpose of follow-up. Staff may follow-up with you for a period of up to 12 months for the purpose of informing you of your HIV test result. I have been informed about HIV testing and its benefits and limitations and I’ve discussed it with my test counselor. I understand that some tests require a second specimen to be taken from me for further testing. I consent to be tested.                                                                                                                                                              

By signing below, I understand:  • The proposed test(s) and the procedure for obtaining a specimen. • The benefits and possible risks of testing. • Additional counseling and assistance with health care and other services are available if I need them. • The potential for false positive and negative results. • My test results will be kept confidential.

  I, the signee, hereby authorize the use or disclosure of my protected health information as described below: 1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION The Knights & Orchids Society is authorized to disclose the following protected health information to The West Alabama Women’s Center, UAB Selma Family Medicine, Alabama Department of Public Health and Boca Pharmacy Group. 2.DESCRIPTION OF INFORMATION TO BE DISCLOSED The health information that may be disclosed is:Medical records Communicable diseases (including HIV and AIDS) Mental health records All past, present, and future periods of health care information may be shared.  3. PURPOSE OF THE USE OR DISCLOSURE The purpose of this use or disclosure is to provide treatment and/or prevention services. 4. VALIDITY OF AUTHORIZATION FORM This Authorization Form is valid beginning today and expires in 18 months. 5. ACKNOWLEDGMENT I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it and would then no longer be protected by federal privacy regulations. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization. I have the right to refuse to sign this HIPPA Authorization Form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.   Note*: Although your name is a required part of such information, the name itself will be translated into a code which will be used to distinguish your testing data from that of others. Your testing data will not be identified by name in public health statistics or in any research. We will use your demographics to track your high-risk factors.                                                                     

By signing below, I give TKO Society:  • consent to receive my medical information to assist me with linkage to HIV/STI prevention or treatment. •If I have a confidential HIV test, I understand that Alabama statutes allow my test results to be released only to the persons or under the circumstances per the Alabama HIV confidentiality statue.

Please answer the following questions based on your sexual activity over the last 12 months: