• 818-758-4076
  • office@legit.com
  • 1825 NW 167th Street, Suite 102 Miami Gardens, FL 33056

Home HIV Testing Kit Request Form

The people behind The Center for Family and Child Enrichment

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​

  • Have NOT tested positive for HIV in the past

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

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

  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.

​

Direct 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, work phone number, and extension. This information can be used to report your test results or address any other questions you may have.

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

Pick Up: If you prefer to personally pick up your home testing kit, the testing counselor will inform you about the nearest Center for Family and Child Enrichment (CFCE) health center.

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.

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

Get Your Free HIV Home Test Kit


    Terms & Conditions
    • 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 will 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 result, 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.
    • 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 agree to honestly report my test results.
    • I understand that all the information shared during the phone conversations is confidential.
    • If the test result is reactive, further confirmation testing will be required, which will be conducted in person at a nearby Pediatric & Family Health and Wellness Center location. At that point, additional information and consent forms will be collected by the Pediatric & Family Health and Wellness Center.
    • I understand that 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 Pediatric & Family Health and Wellness Center to contact me regarding any appropriate and eligible referrals.
    Consent and Accept:

    /hipaa-privacy-statement/" target="_blank" style="text-decoration: underline !important;">HIPAA FORMS Service Privacy Statement.
    [/acceptance]

    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
    • I hereby authorize the PFHWC to use or disclose my HIV testing and counseling records for the following reasons (initial all that apply):
      ___ coordination of my referrals to other services
      ___ linkage to and coordination of medical care
      ___ coordination of partner notification with the Department of Health
      ___ conducting scientific research
      ___ managing healthcare operations, or
      ___ teaching.
    • I hereby authorize the PFHWC to release all my HIV testing and counseling records to other institutions, agencies, health care organizations or healthcare providers who accept me for medical or institutional care.
    • 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 disease 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 had an opportunity to review the PFHWC Notice of Privacy Practices which contains a list of special circumstances when disclosure of my PHI is permitted or required under Federal law.
    Consent and Accept:
    Your Signature

    Insurance Options

    We accept a variety of medical and dental insurance plans. If your plan is not listed, or you are uninsured, please call our office for more information.

    Medical

    Blue Cross Blue Shield
    CIGNA
    AETNA
    AVMED
    Humana
    Magellan (Behavioral Health only)
    Simply
    Sunshine Child Welfare
    Staywell/CMS
    United Healthcare
    Miami Children’s Health
    Sunshine Health Plan / Ambetter

    Dental

    CIGNA
    Delta Care
    Delta Dental
    Dentemax
    Dentaquest
    Humana
    Liberty
    MCNA
    United Concordia
    United Healthcare