Form Aa8596 – Fill Out and Use

AMERICAN-AMICABLE LIFE INSURANCE COMPANY OF TEXAS

P.O. BOX 2549 • WACO, TEXAS 76702-2549

WISCONSIN NOTICE AND CONSENT FOR HUMAN IMMUNODEFICIENCY TESTING

To evaulate your insurability, American-Amicable Life Insurance Company of Texas (Insurer) requests that you be tested to determine the presence of human immunodificiency virus (HIV)antibody or antigens. By signing and dating this form, you agree that this test may be done and that underwriting decisions may be based on the test results. A licensed laboratory will perform one or more tests approved by the Wisconsin Commissioner of Insurance.

PRETESTlNG CONSIDERATION

Many public health organizations recommend that, if you have any reason to believe you may have been exposed to HIV, you become informed about the implications of the test before being tested. You may obtain information about HIV and counseling from a private health care provider, a public health clinic, or one of the AIDS service organizations on the attached list. You may also wish to obtain an HlV test from an anonymous counseling and testing site before signing this consent form. The Insurer is prohibited from asking you whether you have been tested at an anonymous counseling and testing site and from obtaining the results of such a test. For further information on these options, contact the Wisconsin AlDSline at 1-800-334-2437.

MEANING OF POSITIVE TEST RESULTS

This is not a test for AIDS. It is a test for HlV and shows whether you have been infected by the virus. A positive test result may have an effect on your ability to obtain insurance. A positive test result does not mean that you have AIDS, but it does mean that you are at a seriously increased risk of developing problems with your immune system. HlV tests are very sensitive and specific. Errors are rare but they can occur. If your test result is positive, you may wish to consider further independent testing from your physician, a public health clinic, or an anonymous HIV counseling and testing site. HIV testing may be arranged by calling the

Wisconsin AlDSline at 1-800-334-2437.

NOTIFICATION OF TEST RESULTS

If your HlV test result is negative, no routine notification will be sent to you. If your HIV test result is other than normal, the Insurer will contact you and ask for the name of a physician or other health care provider to whom you may authorize disclosure and with whom you may wish to discuss the test results.

DISCLOSURE OF TEST RESULTS

All test results will be treated confidentially. The laboratory that does the testing will report the result to the Insurer. If necessary to process your application, the Insurer may disclose your test result to another entity such as a contractor, affiliate, or reinsurer. If your HlV test is positive, the Insurer may report it to the Medical Information Bureau (MIB, Inc.), as described in the notice given to you at the time of application. If your HIV test is negative, no report about it will be made to the MlB, Inc. The organizations described in this paragraph may maintain the test results in a file or data bank. These organizations may not disclose the fact that the test has been done or the results of the test except as permitted by law or authorized in writing by you.

CONSENT

I have read and l understand this notice and consent for HIV testing. I voluntarily consent to this testing , and the disclosure of the test result as described above. A photocopy or facsimile of this form will be as valid as the original.

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Name of Proposed Insured(Print)

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Date of Birth

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RESOURCES FOR PERSONS WITH A POSITIVE HIV TEST

The Wisconsin AlDSline provides accurate, timely information on AIDS/HIV to people throughout Wisconsin. It offers confidential answers to your questions on the implications of a positive HlV antibody test. The Wisconsin AlDSIine also provides a comprehensive listing of HlV-related medical and social services, such as dental and physician care, home care, legal aid, pastoral care, support groups, and counseling and information on Wisconsin’s AIDS service organiza- tions. To contact the Wisconsin AlDSIine, call 1-800-334-2437. In Milwaukee, call (414) 273-2437.

AIDS Resource Centers of Wisconsin provide direct support services to people living with AIDS and HlV infection. Ser- vices include medical referral, financial assistance, legal counsel, emotional support, referral for pastoral care, assis- tance with daily living needs, support groups, and comprehensive care management. Call, visit, or write the AIDS Re- source Center near you:

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THE IMPLICATIONS OF TESTING POSITIVE FOR HIV

A positive test result is not a diagnosis of AIDS. A positive test means that you have HlV infection. Like people with other chronic medical problems, people with HlV infection have a spectrum of conditions, rang- ing from no symptoms to very serious ones. Over time, most people with HlV infection progress along the spectrum toward more serious symptoms. However, both improved medical management and many options for self-care now provide new hope for people with HlV infection. Anti-viral drug therapy and preventive antibiotics can delay progression of HlV infection and postpone or modify complications.

It is extremely important to find a knowledgeable, experienced, and supportive health care provider to work with you in evaluating and managing your HlV infection. If you do not know whom to see, consult your local AIDS Resource Center for a recommendation or call the Wisconsin AIDSline to obtain a referral. In

Wisconsin, call 1-800-334-2437. In Milwaukee, call (414) 273-2437.

Your health care provider can perform periodic examinations and arrange for appropriate tests to help you decide what treatments and interventions you may want to use. Many people with HlV infection are being successfully treated with anti-viral drugs such as zidovudine (AZT) to slow the progress of the infection. Depending on the results of certain tests of your immune system, you may also benefit from therapies to prevent some infections. People with HlV infection also need regular tuberculosis (TB)screening and certain vaccinations. You and your health care provider can work out a schedule of follow-up visits appropriate for you.

You may also want to utilize some self-care options and nonmedical therapies. A nutritious diet, regular exercise, restful sleep, stress reduction, and spiritual peace (which are important for everyone) are even more helpful for many people with HlV infection. Some people with HlV infection find strength in meditation, massage, and specialized diets. If you are HlV positive, it is healthier to avoid alcohol and recreational drugs because they may damage your immune system.

A positive test result may mean that you have to make changes in certain areas of your life. It is much easier to make these adjustments with the help and support of others. There are support groups and counselors at most AIDS service organizations. You might seek support from your partner or trusted friends, family, clergy, or health professionals.

Counseling can help you put things in perspective. Some people who test positive find that counseling assists them in handling social and intimate relationships, dealing with fear, and promoting self-esteem. Professional counseling can help lessen the effects of the numerous issues that you may face.

You have a responsibility to yourself and to others to avoid transmitting the virus. Counselors can help you sort out your feelings about intimate relationships and help you learn about HlV risk-reduction methods. Not only should you avoid infecting others, but you should also avoid getting reinfected. Getting reinfected may help speed up the process of the HlV infection you already have.

Being HIV positive means taking the right steps to maintain your health. Dealing with the fear is healthier than avoiding the knowledge of HlV infection.

For more information on HlV antibody testing and HlV related services, contact the Wisconsin AlDSIine at 1-800-334-2437. In Milwaukee, call (414) 273-2437.

Based on information contained in the brochure The HlV Antibody Test, produced by the American College Health Association.

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