DISCLOSURE & CONSENT TO TESTING
1. Disclosure & Consent for Testing Referral
a. By completing this form, you acknowledge and agree to be referred for HIV and/or sexually transmitted infection (STI) testing services through Healing With Hope Corp. and its partner providers.
b. Participation in testing services is completely voluntary, and you may withdraw your consent at any time.

2. Withdrawal & Data Policy
a. If you choose to withdraw your consent:
i. Your confidential information will be deleted within 24 hours
ii. Demographic information may be retained for program reporting and evaluation purposes
b. If you proceed with testing:
i. Your confidential information will be securely deleted within 72 hours after the completion of your test
ii. Demographic information will be retained for reporting and funding requirements

3. Privacy & Cost Transparency
a. Healing With Hope Corp. is committed to protecting your privacy. Information collected is handled with care and used only to support your access to services.
b. Testing services are typically free and confidential through our programs and partners.

4. Partner Facility Notice (Important)
a. Please note:
i. If you receive a positive test result, the healthcare provider or partner facility may require identification and/or insurance information to support treatment services
ii. If you do not have insurance, you may still receive treatment; however, you may receive a bill
iii. You may also have the option to request a financial assistance program or waiver directly through the provider

5. Agency Policy Disclaimer
a. Healing With Hope Corp. provides referrals and support services.
Policies and procedures may vary by partner agency or healthcare provider.
We encourage you to review and confirm policies directly with the service provider at the time of your visit.
6. Consent Agreement Statement
By signing below, you confirm that:
a. You have read and understand the information above
b. You voluntarily agree to be referred for HIV/STI testing services
c. You understand that you may withdraw consent at any time

LIABILITY WAIVER & LIMITATION OF RESPONSIBILITY
1. Liability Waiver & Acknowledgment
a. By agreeing to participate in testing referral services through Healing With Hope Corp., you acknowledge and understand the following:
b. Healing With Hope Corp. provides education, outreach, and referral services only and does not directly perform medical testing, diagnosis, or treatment.
c. All medical services, including testing, diagnosis, and treatment, are provided by independent healthcare providers or partner agencies, which operate under their own policies, procedures, and standards of care.

2. Responsibility Clarification
a. You understand that Healing With Hope Corp. is not responsible for:
b. The outcome of any test results
c. Medical decisions made by healthcare providers
d. Services, treatment plans, or care provided by partner agencies
e. Any questions or concerns regarding your care should be directed to the licensed healthcare provider or facility performing your services.

3. Voluntary Participation & Risk Acknowledgment
a. You acknowledge that participation in testing services is voluntary, and you may choose to decline or discontinue services at any time.
b. You understand that all medical testing carries some level of risk, and you agree to hold harmless Healing With Hope Corp., its staff, volunteers, and affiliates from any claims, liabilities, or damages arising from services provided by third-party healthcare providers.

4. Agreement Statement
a. By signing below, you confirm that:
b. You have read and understood this liability waiver
c. You agree to participate voluntarily
d. You release Healing With Hope Corp. from liability related to third-party medical services