Read these before you sign. Each box is a separate decision — the last two are genuinely optional and declining them changes nothing about your care.
1. What you're consenting to
You're agreeing to let Equity Alliance Health ("EAH") screen and test you at the Community Testing Event on August 29, 2026. That may include a rapid HIV test performed with a fingerstick or oral swab, and any other screening you selected above.
An HIV test looks for antibodies or antigens that show whether HIV is present. A non-reactive ("negative") result means nothing was detected — but no test detects a very recent infection, so a non-reactive result does not rule out an exposure in the preceding weeks. A reactive ("preliminary positive") result is not a diagnosis on its own; it must be confirmed by an additional laboratory test. Rapid tests can occasionally produce false reactive and false non-reactive results.
Testing is voluntary. You may refuse any test, and you may withdraw your consent at any point up to the moment the specimen is collected. Refusing does not affect any other service EAH provides to you. EAH also cannot require an HIV test as a condition of receiving other care.
2. Your right to anonymous testing
Under Illinois law you have the right to be tested anonymously, using a code instead of your name. This preregistration form is for confidential testing, which records your result in a protected health record under your name. If you would prefer anonymous testing, do not submit this form — come to the event and ask staff for anonymous testing, or ask us to refer you to a site that provides it.
3. How your results are handled
Results are given to you directly and in private. EAH will not release your HIV test result to anyone else except where you give written authorization, or where release is permitted or required by law. Illinois protects HIV-related information more strictly than most health information under the AIDS Confidentiality Act (410 ILCS 305), and a violation of that Act carries penalties.
Two things happen by operation of law, regardless of your preferences, and you should know about them before you test:
- Reporting. Confirmed positive HIV results are reported to the Illinois Department of Public Health, as required for all reportable communicable diseases. That report is protected and is not public.
- Partner services. Public health staff may offer to notify people who may have been exposed. This service is voluntary for you, and your name is never given to the person being notified.
If your result is reactive, an EAH staff member will stay with you, arrange confirmatory testing, and connect you to treatment the same day where possible. Effective treatment means a normal lifespan and, once the virus is undetectable, no sexual transmission to partners.
4. Notice of Privacy Practices (HIPAA)
EAH is a covered entity under the Health Insurance Portability and Accountability Act. Our Notice of Privacy Practices explains how we may use and disclose your protected health information for treatment, payment, and health care operations, and lists the disclosures we may make without your authorization — for example, to public health authorities, in response to a court order, or to avert a serious and imminent threat to health or safety. It also explains your rights: to inspect and get a copy of your record, to request corrections, to request restrictions on disclosure, to ask for confidential communications at an alternate address or number, to receive an accounting of certain disclosures, and to be notified if your information is breached.
You can read the full Notice at equityah.org/privacy, request a paper copy at the event, or call our Privacy Officer. Acknowledging that you received the Notice is not the same as consenting to any particular use of your information, and it does not waive any right.
5. Payment and financial responsibility
HIV testing and all screenings listed on this form are provided at no charge to you at this event. If you receive a billable service beyond those and you asked us to bill your insurance, you authorize EAH to submit claims on your behalf and to release the minimum information necessary to your health plan for that purpose, and you assign your benefits directly to EAH. You remain responsible for any patient balance your plan does not cover, subject to our sliding fee scale and financial assistance policy. Ask any staff member for that policy — no one is denied service for inability to pay.
If you told us not to bill your insurance, we will not submit a claim, and no Explanation of Benefits will be generated.
6. Accuracy and limits of this form
You confirm the information you've given is accurate and complete to the best of your knowledge. This form is a preregistration, not a medical appointment and not a diagnosis. It does not create a physician–patient relationship, and it is not monitored. If you have a medical emergency, call 911. Do not use this form to report symptoms or ask for medical advice.
Submitting this form reserves a place in line; it does not guarantee a specific appointment time. EAH may reschedule or cancel the event, and will notify you at the contact information you provided.
7. Nondiscrimination and access
EAH complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Free language assistance and auxiliary aids are available at no cost — ask at the registration table or note it in the interpreter question above.
8. Security of this submission
This form is transmitted over an encrypted connection and stored in EAH's secure system. Email and text messages are not fully secure; if you asked us to contact you that way, you accept that risk for the limited content you authorized. You can change your contact preferences at any time by calling us.
