Required HIV Related Consent and Authorization Forms
Informed Consent to Perform an HIV Test
The decision to have an HIV test is voluntary. In order to have an HIV test in New York State, you must give your consent in writing.
- English (DOH 2556 and DOH 2556i) - Signature format (booklet) (PDF, 147 KB, 3pg.)
- English (DOH 2556 and DOH 2556i) (PDF, 147 KB, 5pg.)
- Download on the link above, or, for printed copies, complete the Order Form at www.hivguidelines.org (supplies are limited).
- Spanish (DOH 2556ES and DOH 2556iES) - Signature format (booklet) (PDF, 73 KB, 3pg.)
- Spanish (DOH 2556ES and DOH 2556iES) (PDF, 119 KB, 5pg.)
- Download on the link above, or, for printed copies, complete the Order Form at www.hivguidelines.org (supplies are limited).
- Arabic (DOH 2556ar and DOH 2556(i)ar) - Signature format (booklet) (PDF, 96 KB, 3pg.)
- Arabic (DOH 2556ar) (PDF, 128 KB, 5pg.)
- Bengali (DOH 2556BN and DOH 2556iBN) - Signature format (booklet) (PDF, 109 KB, 3pg.)
- Bengali (DOH 2556BN) (PDF, 192 KB, 5pg.)
- French (DOH 2556fr and DOH 2556(i)fr) - Signature format (booklet) (PDF, 94 KB, 3pg.)
- French (DOH 2556fr) (PDF, 97 KB, 5pg.)
- German (DOH 2556DE and DOH 2556iDE) - Signature format (booklet) (PDF, 81 KB, 3pg.)
- German (DOH 2556DE) (PDF, 134 KB, 5pg.)
- Haitain Creole (DOH 2556ht and DOH 2556(i)ht) - Signature format (booklet) (PDF, 68 KB, 3pg.)
- Haitian Creole (DOH 2556ht) (PDF, 117 KB, 5pg.)
- Hebrew (DOH 2556he and DOH 2556(i)he) - Signature format (booklet) (PDF, 200 KB, 3pg.)
- Hebrew (DOH 2556he) (PDF, 225 KB, 5pg.)
- Hindi (DOH 2556hi and DOH 2556(i)hi) - Signature format (booklet) (PDF, 425 KB, 3pg.)
- Hindi (DOH 2556hi) (PDF, 665 KB, 5pg.)
- Italian (DOH 2556it and DOH 2556(i)it) - Signature format (booklet) (PDF, 52 KB, 3pg.)
- Italian (DOH 2556it) (PDF, 79 KB, 5pg.)
- Japanese (DOH 2556ja and DOH 2556(i)ja) - Signature format (booklet) (PDF, 215 KB, 3pg.)
- Japanese (DOH 2556ja) (PDF, 295 KB, 5pg.)
- Korean (DOH 2556KO and DOH 2556iKO) - Signature format (booklet)(PDF, 270 KB, 3pg.)
- Korean (DOH 2556KO) (PDF, 336 KB, 5pg.)
- Laotian (DOH 2556LO and DOH 2556iLO) - Signature format (booklet) (PDF, 105 KB, 3pg.)
- Laotian (DOH 2556LO) (PDF, 174 KB, 5pgs)
- Polish (DOH 2556pl and DOH 2556(i)pl) - Signature format (booklet) (PDF, 117 KB, 3pg.)
- Polish (DOH 2556pl) (PDF, 136 KB, 5pg.)
- Portuguese (DOH 2556PT and DOH 2556iPT - Signature format (booklet)) (PDF, 78 KB, 3pgs)
- Portuguese (DOH 2556PT) (PDF, 118 KB, 5pg.)
- Russian (DOH 2556ru and DOH 2556(i)ru) - Signature format (booklet) (PDF, 87 KB, 3pg.)
- Russian (DOH 2556ru) (PDF, 136 KB, 5pg.)
- Thai (DOH 2556th and DOH3556(i)th) - Signature format (booklet) (PDF, 4 MB, 3pg.)
- Thai (DOH 2556th) (PDF, 8 MB, 5pg.)
- Traditional Chinese (DOH 2556ZH and DOH 2556iZH) - Signature format (booklet) (PDF, 331 KB, 3pg.)
- Traditional Chinese (DOH 2556ZH) (PDF, 359 KB, 5pg.)
- Turkish (DOH 2556TR and DOH 2556iTR) - Signature format (booklet) (PDF, 160 KB, 3pg.)
- Turkish (DOH 2556TR) (PDF, 203 KB, 5pg.)
- Twi (DOH 2556tw and DOH 2556(i)tw) - Signature format (booklet) (PDF, 583 KB, 3pg.)
- Twi (DOH 2556tw) (PDF, 773 KB, 5pg.)
- Urdu (DOH 2556ur and DOH 2556(i)ur) - Signature format (booklet) (PDF, 1.7 MB, 3pg.)
- Urdu (DOH 2556ur) (PDF, 1.8 MB, 5pg.)
- Vietnamese (DOH 2556vi and DOH 2556(i)vi) - Signature format (booklet) (PDF, 118 KB, 3pg.)
- Vietnamese (DOH 2556vi) (PDF, 200 KB, 5pg.)
- Yoruba (DOH 2556YO and DOH 2556iYO) - Signature format (booklet) (PDF, 70 KB, 3pg.)
- Yoruba (DOH 2556YO) (PDF, 111 KB, 5pg.)
Informed Consent to Perform a Confidential HIV Test and Authorization for Release of HIV-related Information for Purposes of Providing Post-exposure Care to a Health Care Worker Exposed to a Patient's Blood or Body Fluids.
- English (DOH-4054, Rev. 5/09) (PDF, 53 KB, 2pg.)
Note: Spanish version is in revision. Please print and use 2556ES and 2557ES instead of 4054S.
HIPAA Compliant Authorization for Release of Medical Information and Confidential HIV Related Information
Requests for information in an alternate format can be made by sending an e-mail note to hivct@health.state.ny.us
- English (DOH-2557, Rev. 8/05) (PDF, 52 KB, 3pg.)
- Form 2557: Technical Assistance Bulletin (PDF, 42 KB, 2pg.)
- Spanish (DOH-2557ES, Rev. 8/05) (PDF, 46 KB, 3pg.)
Consent for Expedited HIV Testing in the Delivery Setting (DOH 4158)
The consent form for expedited testing in the delivery system has been revised to be in accordance with the HIV reporting and partner notification regulations.
- English (PDF, 32 KB, 2pg.)
- Spanish (PDF, 47 KB, 2pg.)
- Chinese (PDF, 1.36 MB, 2pg.)
- French (PDF, 48 KB, 2pg.)
- Haitian/Creole ( PDF, 44 KB, 2pg.)
- Russian ( PDF, 52 KB, 2pg.)
Sample Release Form Regarding Exchange of Domestic Violence and HIV-Related Information
Complaint Report for Alleged Violation of Article 27F
- English (DOH - 2865, 12/00) - (PDF, 52 KB, 1pg.)