Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 757 NH (2004/07)
New Hampshire HIV
Antibody/Antigen Consent and
Testing Form
ACORD New Hampshire HIV Antibody/Antigen Consent and Testing Form (ACORD 757
NH), needs to be signed by the insured or proposed insured in order to authorize HIV
screening to occur.
IDENTIFICATION SECTION Company
Name and Address of Insurance
Name of Insurance Company must be inserted before this form is used. Use the actual
name of the company. Do not use group names.
PHYSICIAN OR OTHER
PERSON/ENTITY
Name of Physician or Other
Person/Entity
Name of physician or other person/entity authorized by the Proposed Insured to disclose
positive or indeterminate test result.
PHYSICIAN OR OTHER
PERSON/ENTITY
Street Address
Indicate the address of the physician or other person/entity. Do not use P.O. Box number.
PHYSICIAN OR OTHER
PERSON/ENTITY
City
Indicate the city of the address.
PHYSICIAN OR OTHER
PERSON/ENTITY
State
State of the address.
PHYSICIAN OR OTHER
PERSON/ENTITY
Zip
Zip code, postal code, etc. (country dependent)
INFORMED CONSENT
Proposed Insured
Full name of the proposed insured. Please print if handwritten.
INFORMED CONSENT
Date of Birth
Indicate the date of birth of the proposed insured in MM/DD/YYYY format.
INFORMED CONSENT
Signature of Proposed Insured
Proposed Insured must sign the form.
INFORMED CONSENT
Date
Date Proposed Insured signed the form.
INFORMED CONSENT
State of Residence
Indicate the state of residence of the proposed insured.
INFORMED CONSENT
Signature of Witness
Witness must sign the form.
ACORD 757 NH (2004/07)
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