Justification for the Non-Substantive Changes - 0500

Justification for Non-Substantive Changes for

Forms SSA-4814-F5 and SSA-4815-F6

Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child

20 CFR 416.933-416.934

OMB No. 0960-0500

Background

In mid-2016, SSA received OMB approval for extensive changes to forms SSA-4814-F5 and SSA‑4815-F6, which we use to collect medical information on adults and children, respectively, alleging disability due to human immunodeficiency virus (HIV) infection. These changes were the result of anticipated regulatory updates to our medical listings for evaluation of HIV infection. However, we encountered some difficulties due to the differing timelines required for OMB approval and publication of the final rule containing the updates to the medical listings and OMB approval for the SSA-4814-F5 and SSA-4815-F6.

The content of this form largely reflects the content of the listings, so the SSA-4814-F5 and SSA‑4815-F6 must directly reflect the versions of the listings in force at any given time. The changes to the listings become effective on January 17, 2017, which is also the date on which we plan to implement the forms. Our ability to make certain payments correctly under the Supplemental Security Income program depends largely on this form; if the form does not directly reflect the listing requirements, we may make incorrect decisions regarding such payments.

Revision to the SSA-4814-F5:

• Change #1: In the description for the first checkbox under item C.7.a., change “200 cells/mm³ or less” to “less than 200 cells/mm³.”

Justification #1: We made this change to be consistent with the regulatory text.

Revisions to the SSA-4815-F6:

• Change #1: We have fixed a minor formatting error on page 1 to connect the vertical line separating the columns in section C. In the form submitted to OMB, the column had a short disconnection in a portion of the vertical line separating item C.1. and item C.6.

Justification #1: We are concerned that the disconnection is distracting from the content of the form.

• Change #2: On page 4, we removed a line of white space between items 1 and 2.

Justification #2: We made this edit for consistency between line items.

• Change #3: On page 4, we added a line of white space between items 2 and 3.

Justification #3: We made this edit for consistency between line items.

• Change #4: On page 4, under item 3, we have moved “your patient’s” from line 3 to line 2 of the item.

Justification #4: We made this edit for formatting purposes.

• Change #5: On page 4, we removed the “-BK” from the form name in the title.

Justification #5: We made this change to be consistent throughout the form.

• Change #6: On page 6, table 1, row 24, column 1, we have updated the value “66.6” to “66.5.”

Justification #6: We made this change to be consistent with the table that appears in the regulatory text.

SSA will implement the changes to the SSA-4814-F5 and SSA-4815-F6 upon OMB approval.

This action does not affect the public reporting burden.