Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 757 WA (2010/05)
Washington HIV Antibody /
Antigen Consent and Testing
Form
ACORD 757 WA, Washington HIV Antibody / Antigen Consent and Testing Form, is used
to provide authorization for HIV screening. The insured or proposed insured must sign the
form.
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.
CONSENT
Proposed Insured Name (Please
Print)
Full name of the proposed insured. Please print if handwritten.
CONSENT
Address of Proposed Insured
Name
Indicate the address of the Proposed Insured. Do not use P.O. Box number.
CONSENT
Signature of Proposed Insured or
Parent / Guardian
Proposed Insured or Parent / Guardian, if applicable, must sign and date the form.
CONSENT
Signature of Person Obtaining
Consent
Person obtaining consent must sign the form.
CONSENT
Name of Person Obtaining
Consent (Please Print)
Full name of the person obtaining consent. Please print if handwritten.
PHYSICIAN, HEALTH CARE
PROVIDER OR HEALTH
CARE AGENCY
First Name
First name of the designated physician or health care provider.
PHYSICIAN, HEALTH CARE
PROVIDER OR HEALTH
CARE AGENCY
Middle Name
Middle name of the designated physician or health care provider.
PHYSICIAN, HEALTH CARE
PROVIDER OR HEALTH
CARE AGENCY
Last Name
Last name of the designated physician or health care provider.
PHYSICIAN, HEALTH CARE
PROVIDER OR HEALTH
CARE AGENCY
Address (No P.O. Box) Line 1
Indicate the address of the designated physician, health care provider or health care
agency. Do not use P.O. Box number.
PHYSICIAN, HEALTH CARE
PROVIDER OR HEALTH
CARE AGENCY
Line 2
Address - Line 2.
PHYSICIAN, HEALTH CARE
PROVIDER OR HEALTH
CARE AGENCY
City
Indicate the city of the address.
PHYSICIAN, HEALTH CARE
PROVIDER OR HEALTH
CARE AGENCY
State
State of the address.
ACORD 757 WA (2010/05)
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Section Name
Field Name
Field and/or Section Description
PHYSICIAN, HEALTH CARE
PROVIDER OR HEALTH
CARE AGENCY
Zip
Zip code, postal code, etc. (country dependent)
PHYSICIAN, HEALTH CARE
PROVIDER OR HEALTH
CARE AGENCY
Health Care Provider / Agency
Indicate the name of the health care provider or agency.
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
INFORMATION
Agency Code
Identification code assigned to the agency or brokerage firm by the insurance company
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.
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