UWM Non-Employee Consent for Screening or
Confirmatory Tests for Hepatitis B Virus
The undersigned hereby gives permission and consent to the University of Wisconsin-Milwaukee to perform a screening or confirmatory test for the Hepatitis B virus (HBV) as considered necessary or essential for my protection or the protection of patients and employees of the long term care nursing facility where I am a resident.
I understand that the results of the screening or confirmatory tests will be held in strict confidence by the University and will be reviewed only with me, unless I give additional consent for disclosure of the results of such tests.
I further understand that the results of these tests may not be disclosed and that the University may not be compelled to disclose such information or test results involving communicable diseases, except as may be provided under state and federal law.
This consent and authorization given this_______day of _______________, 20______.
__________________________________________
Patient
__________________________________________
Patient's authorized medical representative or responsible party
The undersigned refuses to give consent or submit any screening or confirmatory tests for any of the communicable diseases set forth and enumerated at the University of Wisconsin-Milwaukee.
Dated:___________________________________
_________________________________________
Patient
__________________________________________
Patient's authorized medical representative or responsible party
Updated October 29, 2007 by SAK