Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection (current)

FORM APPROVED
OMB NO. 0960-0500

SOCIAL SECURITY ADMINISTRATION

MEDICAL REPORT ON ADULT WITH ALLEGATION OF
HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION

FO CODE:

The individual named below has filed an application for a period of disability and/or disability payments.
If you complete this form, your patient may be able to receive early payments. (This is not a request for an
examination, but for existing medical information.)

MEDICAL RELEASE INFORMATION
Form SSA-827, "Authorization to Disclose Information to the Social Security Administration (SSA)," attached.
I hereby authorize the medical source named below to release or disclose to the Social Security Administration or
State agency any medical records or other information regarding my treatment for human immunodeficiency virus
(HIV) infection.
DATE
CLAIMANT'S SIGNATURE (Required only if Form SSA-827 is NOT attached)

A. IDENTIFYING INFORMATION
CLAIMANT'S NAME

CLAIMANT'S SSN

CLAIMANT'S PHONE NUMBER

CLAIMANT'S ADDRESS

CLAIMANT'S DATE OF BIRTH

MEDICAL SOURCE'S NAME

B. HOW WAS HIV INFECTION DIAGNOSED?

Other clinical and laboratory findings, medical
history, and diagnosis(es) indicated in the
medical evidence

Laboratory testing confirming HIV infection

C. OPPORTUNISTIC AND INDICATOR DISEASES: Please check if applicable.
BACTERIAL INFECTIONS
1.

MYCOBACTERIAL INFECTION (e.g., caused
by M. avium-intracellulare, M. kansasii, or M.
tuberculosis), at a site other than the lungs, skin,
or cervical or hilar lymph nodes

11.

HISTOPLASMOSIS, at a site other
than the lungs or lymph nodes

12.

MUCORMYCOSIS

13.

PNEUMOCYSTIS PNEUMONIA OR
EXTRAPULMONARY PNEUMOCYSTIS
INFECTION

2.

PULMONARY TUBERCULOSIS,
resistant to treatment

3.

NOCARDIOSIS

4.

SALMONELLA BACTEREMIA, recurrent nontyphoid

14.

5.

SYPHILIS OR NEUROSYPHILIS (e.g.,
meningovascular syphilis) resulting in neurologic
or other sequelae

15.

6.

PROTOZOAN OR HELMINTHIC
INFECTIONS

MULTIPLE OR RECURRENT BACTERIAL
INFECTION(S), including pelvic inflammatory
disease, requiring hospitalization or intravenous
antibiotic treatment 3 or more times in 1 year

FUNGAL INFECTIONS
ASPERGILLOSIS

8.

CANDIDIASIS involving the esophagus, trachea,
bronchi, or lungs, or at a site other than the skin,
urinary tract, intestinal tract, or oral or
vulvovaginal mucous membranes
COCCIDIOIDOMYCOSIS, at a site other than
the lungs or lymph nodes

10.

CRYPTOCOCCOSIS, at a site other than the
lungs (e.g., cryptococcal meningitis)
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TOXOPLASMOSIS of an organ other than the
liver, spleen, or lymph nodes

VIRAL INFECTIONS
17.
18.

7.

9.

16.

CRYPTOSPORIDIOSIS, ISOSPORIASIS, OR
MICROSPORIDIOSIS, with diarrhea lasting
for 1 month or longer
STRONGYLOIDIASIS, extra-intestinal

19.

20.
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CYTOMEGALOVIRUS DISEASE, at a site
other than the liver, spleen, or lymph nodes
HERPES SIMPLEX VIRUS causing mucocutaneous infection (e.g., oral, genital, perianal)
lasting for 1 month or longer; or infection at a
site other than the skin or mucous membranes
(e.g., bronchitis, pneumonitis, esophagitis, or
encephalitis); or disseminated infection
HERPES ZOSTER, disseminated or with
multidermatomal eruptions that are resistant to
treatment
PROGRESSIVE MULTIFOCAL
LEUKOENCEPHALOPATHY

21.

HEPATITIS, resulting in chronic liver
disease manifested by appropriate findings (e.g.,
persistent ascites, bleeding esophageal varices,
hepatic encephalopathy)

31.

MALIGNANT NEOPLASMS
22.

CARCINOMA OF THE CERVIX, invasive, FIGO
stage II and beyond

23.

KAPOSI'S SARCOMA, with extensive oral lesions;
or involvement of the gastrointestinal tract, lungs,
or other visceral organs; or involvement of the skin
or mucous membranes with extensive fungating or
ulcerating lesions not responding to treatment

24.

LYMPHOMA of any type (e.g., primary lymphoma
of the brain, Burkitt's lymphoma, immunoblastic
sarcoma, other non-Hodgkin's lymphoma,
Hodgkin's disease)
SQUAMOUS CELL CARCINOMA OF THE ANAL
CANAL OR ANAL MARGIN

25.

HIV WASTING SYNDROME
32.

33.

CONDITIONS OF THE SKIN OR MUCOUS
MEMBRANES, with extensive fungating or
ulcerating lesions not responding to treatment
(e.g., dermatological conditions such as eczema
34.
or psoriasis, vulvovaginal or other mucosal candida,
condyloma caused by human papillomavirus,
genital ulcerative disease)
35.

ANEMIA (hematocrit persisting at 30 percent or
less), requiring one or more blood transfusions on
an average of at least once every 2 months

28.

GRANULOCYTOPENIA, with absolute neutrophil
3
counts repeatedly below 1,000 cells/mm and
documented recurrent systemic bacterial infections
occurring at least 3 times in the last 5 months

29.

THROMBOCYTOPENIA, with platelet counts
3
repeatedly below 40,000/mm with at least one
spontaneous hemorrhage, requiring transfusion
in the last 5 months; or intracranial bleeding in the
last 12 months

NEUROLOGICAL ABNORMALITIES
30.

DIARRHEA, lasting for 1 month or longer,
resistant to treatment, and requiring intravenous
hydration, intravenous alimentation, or tube
feeding

CARDIOMYOPATHY
CARDIOMYOPATHY (chronic heart failure, or
cor pulmonale, or other severe cardiac
abnormality not responsive to treatment)

NEPHROPATHY

HEMATOLOGIC ABNORMALITIES
27.

HIV WASTING SYNDROME, characterized by
involuntary weight loss of 10 percent or more of
baseline (or other significant involuntary weight
loss) and, in the absence of a concurrent illness
that could explain the findings, involving: chronic
diarrhea with 2 or more loose stools daily lasting
for 1 month or longer; or chronic weakness and
documented fever greater than 38° C (100.4°F)
for the majority of 1 month or longer

DIARRHEA

SKIN OR MUCOUS MEMBRANES
26.

OTHER NEUROLOGICAL MANIFESTATIONS
OF HIV INFECTION (e.g., peripheral
neuropathy), with significant and persistent
disorganization of motor function in 2 extremities
resulting in sustained disturbance of gross and
dexterous movements, or gait and station

HIV ENCEPHALOPATHY, characterized by
cognitive or motor dysfunction that limits function
and progresses

NEPHROPATHY, resulting in chronic renal
failure

INFECTIONS RESISTANT
TO TREATMENT OR
REQUIRING HOSPITALIZATION OR
INTRAVENOUS TREATMENT
3 OR MORE TIMES IN 1 YEAR
36.

SEPSIS

37.

MENINGITIS

38.

PNEUMONIA (non-PCP)

39.

SEPTIC ARTHRITIS

40.

ENDOCARDITIS

41.

SINUSITIS, radiographically documented

NOTE: If you have checked any of the boxes in section C, proceed to section E if you have any remarks you wish
to make about this patient's condition. Then, proceed to sections F and G and sign and date the form.
If you have not checked any of the boxes in section C, please complete section D. See part VI of the instruction
sheet for definitions of the terms we use in section D. Proceed to section E if you have any remarks you wish to
make about this patient's condition. Then, proceed to sections F and G and sign and date the form.

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D. OTHER MANIFESTATIONS OF HIV INFECTION
42. a. REPEATED MANIFESTATIONS OF HIV INFECTION, including diseases mentioned in section C, items
1-41, but without the specified findings described above, or other diseases, resulting in significant,
documented, symptoms or signs (e.g., severe fatigue, fever, malaise, involuntary weight loss, pain, night
sweats, nausea, vomiting, headaches, or insomnia).
Please specify:
1. The manifestations your patient has had;
2. The number of episodes occurring in the same 1-year period; and
3. The approximate duration of each episode.
Remember, your patient need not have the same manifestation each time to meet the definition of repeated
manifestations; but, all manifestations used to meet the requirement must have occurred in the same 1-year
period. (See attached instructions for the definition of repeated manifestations.)
If you need more space, please use section E.
MANIFESTATIONS

NO. OF EPISODES IN THE SAME
1-YEAR PERIOD

DURATION OF EACH EPISODE

EXAMPLE: DIARRHEA

3

1 MONTH EACH

AND
b. ANY OF THE FOLLOWING:
Marked limitation of ACTIVITIES OF DAILY LIVING; or
Marked limitation in maintaining SOCIAL FUNCTIONING; or
Marked limitation in completing tasks in a timely manner due to deficiencies in CONCENTRATION,
PERSISTENCE, OR PACE.
E. REMARKS: (Please use this space if you lack sufficient room in section D or to provide any other comments you wish
about your patient.)

F. MEDICAL SOURCE'S NAME AND ADDRESS (Print or type)

TELEPHONE NUMBER (Area Code)

DATE

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who
knowingly gives a false statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be subject to a fine or imprisonment.
G. SIGNATURE AND TITLE (e.g., physician, R.N.) OF PERSON COMPLETING THIS FORM

FOR
OFFICIAL
USE
ONLY

FIELD OFFICE DISPOSITION:
DISABILITY DETERMINATION SERVICES DISPOSITION:

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MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED SSA-4814-F5
(Medical Report On Adult With Allegation Of Human Immunodeficiency Virus (HIV) Infection)
Your patient, identified in section A of the attached form, has filed a claim for Supplemental Security Income
disability payments based on HIV infection. MEDICAL SOURCE: Please detach this instruction sheet and use
it to complete the attached form.

I. PURPOSE OF THIS FORM:
IF YOU COMPLETE AND RETURN THE ATTACHED FORM PROMPTLY, YOUR PATIENT MAY BE
ABLE TO RECEIVE PAYMENTS WHILE WE ARE PROCESSING HIS OR HER CLAIM FOR
ONGOING DISABILITY PAYMENTS. This is not a request for an examination. At this time, we simply
need you to fill out this form based on existing medical information. The State Disability Determination
Services will contact you later to obtain further evidence needed to process your patient's claim.

II. WHO MAY COMPLETE THIS FORM:
A physician, nurse, or other member of a hospital or clinic staff, who is able to confirm the diagnosis and
severity of the HIV disease manifestations based on your records, may complete and sign the form.

III. MEDICAL RELEASE:
An SSA medical release (an SSA-827) signed by your patient should be attached to the form when you
receive it. If the release is not attached, the medical release section on the form itself should be signed
by your patient.

IV. HOW TO COMPLETE THE FORM:
• If you receive the form from your patient and section A has not been completed, please fill in the

identifying information about your patient.
• You may not have to complete all of the sections on the form.
• ALWAYS COMPLETE SECTION B.
• COMPLETE SECTION C, IF APPROPRIATE . If you check at least one of the items in section C, go

right to section E.
• ONLY COMPLETE SECTION D IF YOU HAVE NOT CHECKED ANY ITEM IN SECTION C. See the

special information below which will help you to complete section D.
•

COMPLETE SECTION E IF YOU WISH TO PROVIDE COMMENTS ON YOUR PATIENT'S
CONDITION(S).

•

ALWAYS COMPLETE SECTIONS F AND G.
NOTE: This form is not complete until it is signed.

V. HOW TO RETURN THE FORM TO US:
•

Mail the completed, signed form, as soon as possible, in the return envelope provided.

• If you received the form from your patient without a return envelope, give the completed, signed form

back to your patient for return to the SSA field office.

VI. SPECIAL INFORMATION TO HELP YOU COMPLETE SECTION D
HOW WE USE SECTION D:
• Section D asks you to tell us what other manifestations of HIV your patient may have. It also asks you to

give us an idea of how your patient's ability to function has been affected.
• We do not need detailed descriptions of the functional limitations imposed by the illness; we just need to

know whether your patient's ability to function has been affected to a "marked" degree in any of the
areas listed. See below for an explanation of the term "marked."
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SPECIAL TERMS USED IN SECTION D
WHAT WE MEAN BY "REPEATED" MANIFESTATIONS OF HIV INFECTION: (See Item 42.a)
"Repeated" means that a condition or combination of conditions:
• Occurs an average of 3 times a year, or once every 4 months, each lasting 2 weeks or more; or
• Does not last for 2 weeks, but occurs substantially more frequently than 3 times in a year or once every

4 months; or
• Occurs less often than an average of 3 times a year or once every 4 months but lasts substantially
longer than 2 weeks.

WHAT WE MEAN BY "MANIFESTATIONS OF HIV INFECTION": (See Item 42.a)
• "Manifestations of HIV infection" may include:

Any condition listed in section C, but without the findings specified there (e.g., carcinoma of the cervix
not meeting the criteria shown in item 22 of the form, diarrhea not meeting the criteria shown in item 33
of the form); or any other condition that is not listed in section C (e.g., oral hairy leukoplakia, myositis,
pancreatitis, hepatitis, peripheral neuropathy, glucose intolerance, muscle weakness, cognitive or other
mental limitation).
•

Manifestations of HIV must result in significant, documented, symptoms and signs (e.g., severe fatigue,
fever, malaise, involuntary weight loss, pain, night sweats, nausea, vomiting, headaches, or insomnia).

WHAT WE MEAN BY "MARKED" LIMITATION IN FUNCTIONING: (See Item 42.b)
• When "marked" is used to describe functional limitations, it means more than moderate, but less than

extreme. "Marked" does not imply that your patient is confined to bed, hospitalized, or in a nursing home.
• A marked limitation may be present when several activities or functions are impaired or even when only

one is impaired. An individual need not be totally precluded from performing an activity to have a marked
limitation, as long as the degree of limitation is such as to seriously interfere with the ability to function
independently, appropriately, and effectively.

WHAT WE MEAN BY "ACTIVITIES OF DAILY LIVING": (See Item 42.b)
• Activities of daily living include, but are not limited to, such activities as doing household chores,

grooming and hygiene, using a post office, taking public transportation, and paying bills.
• EXAMPLE: An individual with HIV infection who, because of symptoms such as pain, imposed by the

illness or its treatment, is not able to maintain a household or take public transportation on a sustained
basis or without assistance (even though he or she is able to perform some self-care activities) would
have marked limitation of activities of daily living.

WHAT WE MEAN BY "SOCIAL FUNCTIONING": (See Item 42.b)
•

Social functioning includes the capacity to interact appropriately and communicate effectively with others.

• EXAMPLE: An individual with HIV infection who, because of symptoms or a pattern of exacerbation and

remission caused by the illness or its treatment, cannot engage in social interaction on a sustained basis
(even though he or she is able to communicate with close friends or relatives) would have marked
limitation in maintaining social functioning.

WHAT WE MEAN BY "COMPLETING TASKS IN A TIMELY MANNER": (See Item 42.b)
• Completing tasks in a timely manner involves the ability to sustain concentration, persistence, or pace to

permit timely completion of tasks commonly found in work settings.
• EXAMPLE: An individual with HIV infection who, because of HIV-related fatigue or other symptoms, is

unable to sustain concentration or pace adequate to complete simple work-related tasks (even though
he or she is able to do routine activities of daily living) would have marked limitation in completing tasks.
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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1633(e)(1) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to make a determination on a claimant’s disability claim.
The information you furnish on this form is voluntary. However, failure to provide us with the requested
information could prevent us from making an accurate or timely decision on the named individual’s disability
claim.
We rarely use the information you supply for any purpose other than for determining eligibility. However, we
may use it for the administration and integrity of Social Security programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, including but not limited to the
following:
1.

To enable a third party or an agency to assist Social Security in establishing rights to Social Security
benefits and/or coverage;

2.

To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans’ Affairs);

3.

To make determinations for eligibility in similar health and income maintenance programs at the Federal
State, and local level; and,

4.

To facilitate statistical research, audit or investigative activities necessary to assure the integrity of Social
Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare
our records with records kept by other Federal, State, or local government agencies. Information from these
matching programs can be used to establish or verify a person’s eligibility for Federally-funded or administered
benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Record Notice entitled, the
Master Beneficiary Record (60-0090). Additional information about this and other systems of records notices
and our programs are available from our Internet website at www.socialsecurity.gov or at your local Social
Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB
control number for this collection is 0960-0500. We estimate that it will take between 10 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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