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Home HIV Testing Kit Request Form

We appreciate your engagement with our HIV Home Testing initiative. 

 

This testing option is accessible for individuals aged 17 and above, provided they fulfill the requirements below:

  • Live in Miami-Dade​

  • You must be 17 years of age or older

  • Have NOT tested positive for HIV in the past

  • Have NOT tested in the last two (2) months

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To ensure a comprehensive understanding of the home test process, please read the following information:

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  1. Kindly complete the request form provided below with utmost accuracy and submit it. This information is crucial for effective communication with you.

  2. Within a period of 24 to 48 hours, a testing counselor will contact you to verify the details provided in the form. They will also conduct a risk assessment by asking you standard questions typically included in routine HIV screenings. This phone call is expected to last approximately 5 to 10 minutes.

  3. Upon completion of the assessment, the testing counselor will discuss the method of delivery for an OraQuick home testing kit with you.

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Delivery options:

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  • In-hand Delivery: In most instances, a testing counselor will personally deliver the testing kit to your doorstep. It is important for you to be present at home to receive it. The package will contain an at-home testing kit and contact information of your counselor, including their full name, email address and work phone number. This information can be used to report your test results or address any other questions you may have. 

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  • Pick Up: If you prefer to personally pick up your home testing kit, the testing counselor will inform you of the location of the Pediatric and Family Health and Wellness Center and set a pick-up time & date. 

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  • By Mail: In certain cases, the testing kit can be mailed to your specified address. Please note that it may take up to 3 to 5 business days for the kit to arrive. If the test kit is mailed to you, your counselor will provide their contact information via email.

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Instructions:

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The OraQuick packaging contains the testing instructions. It is important to carefully follow the provided directions. The test should be conducted promptly upon receiving it, and the results should be reported to your counselor without delay.

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If you are prepared to begin, please complete the form below and submit your request.

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Free in-office rapid HIV testing is available at the Pediatric & Family Health and Wellness Center location Monday, Wednesday, Thursday & Friday from 9:00 am - 4:00 pm, Tuesday 10:30 am - 6:00 pm and Saturday 8:00 am - 12:00 pm.

Free Home HIV Test Available Now in Miami-Dade County

Get Your Free HIV Home Test Kit

Terms & Conditions

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  • I have never received a positive HIV test result before. I desire to undergo HIV testing using a no-cost rapid antibody home test kit that can be delivered to my doorstep. 

  • I consent to an initial phone conversation with an HIV testing counselor to discuss my potential risks, provide demographic information, and coordinate the delivery of the test kit.

  • Once I receive the at-home test kit, I will carefully follow the provided instructions to perform the test accurately. If I require any assistance during the testing process, I will contact my testing counselor using the phone number provided.

  • After conducting the HIV test and obtaining the results, I will promptly inform my testing counselor about the results.  If I reach my counselor's voicemail, I will leave my name and phone number for a callback.

  • I agree to honestly report my test results.

  • If more than two (2) days have passed since the delivery of my package, my counselor will reach out to me for a follow-up.  I understand that all information shared during the phone conversation is confidential unless disclosure is required by law.

  • If the test result is reactive (i.e., positive), further confirmation testing will be required, which will be conducted in person at the Pediatric & Family Health and Wellness Center (“PFHWC”) location.  At that point, additional information and consent forms will be collected by the PFHWC.

  • I understand that if my test result is reactive, my local Health Department will contact me to discuss my connection to HIV medical care as well as any sexual or needle-sharing partners.  Voluntary partner services will also be offered to me.

  • I understand that I have the right to withdraw my participation from the testing process at any time, and I will communicate this decision to my Testing Counselor via phone or email.

  • I grant my permission for the PFHWC to contact me regarding any appropriate and eligible referrals.

  • I have carefully reviewed the Client Rights and Responsibilities.


Consent and Accept:
 

​The Pediatric and Family Health and Wellness Center (“PFHWC”) respects your privacy and will not use or disclose your protected health information (“PHI”) without your permission unless permitted or required to do so by law.  

 

Consent to Use and Disclosure of Confidential Records

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  • I hereby authorize the PFHWC to use or disclose my HIV testing and counseling information and records for the following reasons: 

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  • coordination of my referrals to other services;

  • linkage to and coordination of medical care;

  • coordination of partner notification with the Department of Health;

  • managing healthcare operations; or

  • training (without disclosing my personal identifying information).

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  • I understand that my HIV testing and counseling records may relate to such sensitive health conditions, including, but not limited to records which may indicate the presence of a communicable or non-communicable disease, and tests for or records of HIV/AIDS or sexually transmitted diseases.

  • I understand that if I refuse to consent to the use and/or disclosure of my confidential records, State and/or Federal law may still require disclosure without my permission under special circumstances.   (See Fla. Stat. § 384.25).

  • I acknowledge that I have reviewed and understand the HIPAA Notice of Privacy Practices which contains a list of the special circumstances when Federal law permits or requires disclosure of my PHI without my permission.

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Consent and Accept:

Your request has been submitted successfully. Within a period of 24 to 48 hours, a testing counselor will contact you.

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