Fillable Ssa-4814 Medical Report On Adult Wtih Allegation Of Human Immunodeficiency Virus (HIV) Infection

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Ssa-4814 Medical Report On Adult Wtih Allegation Of Human Immunodeficiency Virus (HIV) Infection

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Form SSA-4814 (01-2017) UF
Discontinue Prior Editions
Social Security Administration
MEDICAL REPORT ON ADULT WITH ALLEGATION OF HUMAN
IMMUNODEFICIENCY VIRUS (HIV) INFECTION
Page 1 of 4
OMB NO. 0960-0500
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.
CLAIMANT'S SIGNATURE (Required only if Form SSA-827 is NOT attached)
DATE
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?
Laboratory testing confirming HIV infection
Other clinical and laboratory findings, medical
history, and diagnosis(es) indicated in the
medical evidence
C. CONDITIONS RELATED TO HIV INFECTION: Please check if applicable.
ALL INFORMATION PROVIDED IN THIS SECTION MUST BE SUPPORTED BY DOCUMENTATION IN THE MEDICAL
RECORD. We will request your patient's medical records as part of our case adjudication process.
1. Multicentric (not localized or unicentric) Castleman
disease
Affecting multiple groups of lymph nodes
Affecting organs containing lymphoid tissue
2. Primary central nervous system lymphoma
3. Primary effusion lymphoma
4. Progressive multifocal leukoencephalopathy
5. Pulmonary Kaposi sarcoma
6. CD4 Count: Absolute CD4 count of 50 cells/mm
3
or less
Please indicate measurement, date recorded, AND
ordering provider
7. CD4 level and BMI or hemoglobin measurements
(values do not have to be measured on the same date),
with a and b.
a. CD4 level
Absolute CD4 count of 200 cells/mm
3
or less
OR
CD4 percentage of less than 14 percent
Please indicate measurement, date recorded, AND
ordering provider
AND
b. BMI or hemoglobin
BMI measurement of less than 18.5
OR
Hemoglobin measurement of less than 8.0 grams
per deciliter
Please indicate measurement, date recorded, AND
ordering provider
Form SSA-4814 (01-2017) UF Page 2 of 4
8. Complication(s) of HIV infection requiring at least three hospitalizations within a 12-month period and at least 30
days apart. Each hospitalization must last at least 48 hours, including hours in a hospital emergency department
immediately before the hospitalization. Complications of HIV infection may include infections (common or opportunistic),
cancers, and other conditions.
Complication of HIV Infection
Example: Diarrhea
Date of
Hospitalization
Example:
December 2, 2015
Duration
Example: 2 days
Name of Hospital
Example: Memorial Hospital
D. REMARKS: (Please use this space to provide any other comments you wish about your patient.)
E. MEDICAL SOURCE'S NAME AND ADDRESS (Print or type)
TELEPHONE NUMBER
(Include 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.
F. SIGNATURE AND TITLE (e.g., physician, R.N.) OF PERSON COMPLETING THIS FORM
FOR
OFFICIAL
USE
ONLY
FIELD OFFICE DISPOSITION:
DISABILITY DETERMINATION SERVICES DISPOSITION:
Form SSA-4814 (01-2017) UF Page 3 of 4
MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED SSA-4814
(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.
1. 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.
2. 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.
3. 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.
4. 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 complete at least one of the items in section C, go
to section D.
•
COMPLETE SECTION D IF YOU WISH TO PROVIDE COMMENTS ON YOUR PATIENT'S
CONDITION(S).
•
ALWAYS COMPLETE SECTIONS E AND F. Note: This form is not complete until it is signed.
5. 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.
Form SSA-4814 (01-2017) UF Page 4 of 4
Privacy Act Statement
Collection and Use of Personal Information
Sections 1614(a)(3), 1631(a)(4), 1631(e)(1), and 1633 of the Social Security Act, as amended, allow us to collect
this information. We will use the information you provide to make a determination on the named individual’s
disability claim.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us
from making an accurate and timely decision on the claim. We rarely use the information you supply for any
purpose other than what we state above, however, we may use the information for the administration of our
programs, including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract
with us).
A list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records Notices, 60-0103, entitled Supplemental Security Income Record, and Special Veterans
Benefits, and 60-0320, entitled Electronic Disability (eDIB) Claim File. Additional information about these and
other system of records notices and our programs is available from our Internet website at www.socialsecurity.gov
or at your local Social Security office.
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 incorrect payments or delinquent debts under these programs.
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 about 8 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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Ssa-4814 Medical Report On Adult Wtih Allegation Of Human Immunodeficiency Virus (HIV) Infection

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Completed 15 November 2019

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