Form Aa8596 is a document used to report uncompensated care given to individuals who do not have health insurance. This form is used by hospitals, nursing homes, and other providers of medical services. The purpose of this form is to provide information on the amount of uncompensated care that has been provided. This information can be used by the provider to petition for government assistance or tax relief. Form Aa8596 must be filed annually with the state agency responsible for medicaid reimbursement.The form can be filed online or by mail. Instructions for filing can be found on the reverse side of the form.
Before you decide to complete form aa8596, you will want to find out more about the type of form you're going to work with.
Question | Answer |
---|---|
Form Name | Form Aa8596 |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | HIV, Ste, Kenosha, Plankinton |
P.O. BOX 2549 • WACO, TEXAS
WISCONSIN NOTICE AND CONSENT FOR HUMAN IMMUNODEFICIENCY TESTING
To evaulate your insurability,
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
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
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.
_____________________________________________/___________________
Signature of Proposed Insured or Parent, Guardian, |
Date |
or Health Care Agent |
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_________________________________________________________________________________
Name of Proposed Insured(Print)
_________________________________________________________________________________
Date of Birth
_________________________________________________________________________________
Address |
City, State, and ZIP Code |
Form No. AA8596 (Rev. 1/00) |
(SEND TO HOME OFFICE) |
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
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:
Appleton |
AIDS Resource Center of Wisconsin |
Counties served: Calumet, Fond du Lac, |
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120 North Morrison St., Ste. 201 |
Green Lake, Marquette, Oconto, Outagamie, |
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Appleton, WI 54911 |
Sheboygan, Waupaca, Waushara, Winnebago |
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(920) |
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Fax: (920) |
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Eau Claire |
AIDS Resource Center of Wisconsin |
Counties served: Barron, Buffalo, Burnett, |
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505 Dewey St. South, Ste. 107 |
Chippewa, Clark, Dunn, Eau Claire, Pepin, |
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Eau Claire, WI 54701 |
Pierce, Polk, Rusk, St. Croix, Washburn |
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or |
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P.O. Box 11 |
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Eau Claire, WI |
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(715) |
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Fax: (715) |
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Green Bay |
AIDS Resource Center of Wisconsin |
Counties served: Brown, Door, Kewaunee, |
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824 South Broadway |
Manitowoc, Marinette, Menominee, Shawano |
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Green Bay, WI 54304 |
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or |
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P.O. Box 2040 |
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Green Bay, WI |
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(920) |
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Fax: (920) |
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Kenosha |
AIDS Resource Center of Wisconsin |
Counties served: Jefferson, Kenosha, Racine, |
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1212 57th St. |
Walworth |
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Kenosha, WI 53140 |
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or |
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P.O. Box 0173 |
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Kenosha, WI |
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(414) |
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Fax: (414) |
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La Crosse |
AIDS Resource Center of Wisconsin |
Counties served: Jackson, La Crosse, Monroe, |
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Grandview Center |
Trempealeau, Vernon |
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1707 Main St., Ste. 420 |
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LaCrosse, WI 54601 |
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(608) |
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Fax: (608) |
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Milwaukee |
AIDS Resource Center of Wisconsin |
Counties served: Milwaukee, Ozaukee, |
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820 North Plankinton Road |
Washington, Waukesha |
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Milwaukee, WI 53203 |
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or |
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P.O. Box 92487 |
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Milwaukee, WI |
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(414) |
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Fax: (414) |
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(GIVE TO APPLICANT)
Rhinelander |
AIDS Resource Center of Wisconsin |
COUNTIES SERVED: Florence, Forest, |
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Oneida County Health Department |
Oneida, Price, Vilas |
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P.O. Box 400, Courthouse |
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Rhinelander, WI 54501 |
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(715) |
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Fax: (715) |
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Superior |
Information to be announced. |
Counties served: Ashland, Bayfield, Douglas, |
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Contact Eau Claire office until then. |
Iron, Sawyer |
Wausau |
AIDS Resource Center of Wisconsin |
Counties served: Langlade, Lincoln, Marathon, |
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1105 Grand Avenue, Ste. 3 |
Portage, Taylor, Wood |
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Schofield, WI 54476 |
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(715) |
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Fax: (715) |
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Additional |
Dennis C. Hill |
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Resources: |
Harm Reduction Center |
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` |
AODA Outpatient Clinic |
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4311 West Vliet St. |
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(414) |
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Fax: (414) |
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Survival/Revival Resale
Milwaukee's Best Resale Shop
246 East Chicago St.
Milwaukee, WI 53202
(414)
Wisconsin AIDS Research Consortium
820 North Plankinton Ave.
Milwaukee, WI 53202
or
P.O. Box 92487
Milwaukee, WI
(414)
Fax: (414)
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
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
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
You may also want to utilize some
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
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
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
Based on information contained in the brochure The HlV Antibody Test, produced by the American College Health Association.
(GIVE TO APPLICANT)