Fillable Ssa-4815 Medical Report On Child Wtih Allegation Of Human Immunodeficiency Virus (HIV) Infection

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Ssa-4815 Medical Report On Child Wtih Allegation Of Human Immunodeficiency Virus (HIV) Infection

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Form SSA-4815 (01-2017) UF
Discontinue Prior Editions
Social Security Administration
MEDICAL REPORT ON CHILD WITH ALLEGATION OF HUMAN
IMMUNODEFICIENCY VIRUS (HIV) INFECTION
Page 1 of 9
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 the child's treatment for human immunodeficiency virus
(HIV) infection.
CLAIMANT'S PARENT'S OR GUARDIAN'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: Please indicate measurement, date recorded,
AND ordering provider
a. Birth to attainment of age 1:
Absolute CD4 count of 500 cells/mm
3
or less
CD4 percentage of less than 15 percent
b. Age 1 to attainment of age 5:
Absolute CD4 count of 200 cells/mm
3
or less
CD4 percentage of less than 15 percent
c. Age 5 to attainment of age 18:
Absolute CD4 count of 50 cells/mm
3
or less
Page 2 of 9
7. 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
8. Neurological manifestation of HIV infection including, but not limited to, HIV encephalopathy or peripheral neuropathy,
resulting in one of the following specified impairments. Either both a and b or a and c are required.
a. Neurological manifestation (please specify):
Resulting in b. or c.
b. Each of these items requires two examinations at least 60 days apart. You must check the appropriate impairment and
fill out the table indicating the dates of examination
Loss of previously acquired developmental milestones or intellectual ability (including the sudden onset of a new
learning disability), documented on two examinations at least 60 days apart
Progressive motor dysfunction affecting gait and station or fine and gross motor skills, documented on two
examinations at least 60 days apart
Microcephaly with head circumference that is less than the third percentile for age, documented on two
examinations at least 60 days apart
DATE OF EXAMINATION DETAILS (if applicable)
PROVIDER (if other than the person
completing form)
c.
Brain atrophy, documented by appropriate medically acceptable imaging
DATE OF IMAGING DETAILS (if applicable) IMAGING CENTER
9. Immune suppression and growth failure. Both a and b are required.
a. CD4 count:
From birth to attainment of age 5, CD4 percentage of less than 20 percent
Please indicate measurement, date recorded, AND ordering provider
From age 5 to attainment of age 18, absolute CD4 count of less than 200 cells/mm
3
or CD4 percentage of less than 14
percent. Please indicate measurement, date recorded, AND ordering provider
Form SSA-4815 (01-2017) UF
OR
Page 3 of 9
b. Growth failure:
For children from birth to attainment of age 2, three weight-for-length measurements that are:
• Within a consecutive 12-month period; and
• At least 60 days apart; and
• Less than the third percentile on the appropriate weight-for-length table on pages 6-7.
DATE LENGTH (cm) WEIGHT (kg)
For children age 2 to attainment of age 18, three BMI-for-age measurements that are:
• Within a consecutive 12-month period; and
• At least 60 days apart; and
• Less than the third percentile on the appropriate BMI-for-age table on pages 8-9.
DATE AGE (years and months) BMI
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-4815 (01-2017) UF
Page 4 of 9
MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED SSA-4815
(Medical Report On Child With Allegation Of Human Immunodeficiency Virus (HIV) Infection)
A claim has been filed for your patient, identified in section A of the attached form, 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's parent or guardian 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's
parent or guardian.
4. HOW TO COMPLETE THE FORM:
•
If you receive the form from your patient's parent or guardian 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's parent or guardian for return to the SSA field office.
Form SSA-4815 (01-2017) UF
Form SSA-4815 (01-2017) UF Page 5 of 9
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.
Form SSA-4815 (01-2017) UF Page 6 of 9
Table 1 - Males Birth to Attainment of Age 2 - Third Percentile Values for Weight-for-Length
Length
(Centimeters)
Weight
(Kilograms)
45.0 1.597
45.5 1.703
46.5 1.919
47.5 2.139
48.5 2.364
49.5 2.592
50.5 2.824
51.5 3.058
52.5 3.294
53.5 3.532
54.5 3.771
55.5 4.010
56.5 4.250
57.5 4.489
58.5 4.728
59.5 4.966
60.5 5.203
61.5 5.438
62.5 5.671
63.5 5.903
64.5 6.132
65.5 6.359
66.5 6.584
67.5 6.807
68.5 7.027
69.5 7.245
70.5 7.461
71.5 7.674
72.5 7.885
73.5 8.094
Length
(Centimeters)
Weight
(Kilograms)
74.5 8.301
75.5 8.507
76.5 8.710
77.5 8.913
78.5 9.113
79.5 9.313
80.5 9.512
81.5 9.710
82.5 9.907
83.5 10.104
84.5 10.301
85.5 10.499
86.5 10.696
87.5 10.895
88.5 11.095
89.5 11.296
90.5 11.498
91.5 11.703
92.5 11.910
93.5 12.119
94.5 12.331
95.5 12.546
96.5 12.764
97.5 12.987
98.5 13.213
99.5 13.443
100.5 13.678
101.5 13.918
102.5 14.163
103.5 14.413
Form SSA-4815 (01-2017) UF Page 7 of 9
Table 2 - Females Birth to Attainment of Age 2 - Third Percentile Values for Weight-for-Length
Length
(Centimeters)
Weight
(Kilograms)
45.0 1.613
45.5 1.724
46.5 1.946
47.5 2.171
48.5 2.397
49.5 2.624
50.5 2.852
51.5 3.081
52.5 3.310
53.5 3.538
54.5 3.767
55.5 3.994
56.5 4.220
57.5 4.445
58.5 4.669
59.5 4.892
60.5 5.113
61.5 5.333
62.5 5.552
63.5 5.769
64.5 5.985
65.5 6.200
66.5 6.413
67.5 6.625
68.5 6.836
69.5 7.046
70.5 7.254
71.5 7.461
72.5 7.667
73.5 7.871
Length
(Centimeters)
Weight
(Kilograms)
74.5 8.075
75.5 8.277
76.5 8.479
77.5 8.679
78.5 8.879
79.5 9.078
80.5 9.277
81.5 9.476
82.5 9.674
83.5 9.872
84.5 10.071
85.5 10.270
86.5 10.469
87.5 10.670
88.5 10.871
89.5 11.074
90.5 11.278
91.5 11.484
92.5 11.691
93.5 11.901
94.5 12.112
95.5 12.326
96.5 12.541
97.5 12.760
98.5 12.981
99.5 13.205
100.5 13.431
101.5 13.661
102.5 13.895
103.5 14.132
Form SSA-4815 (01-2017) UF Page 8 of 9
Table 3 - Males Age 2 to Attainment of Age 18 - Third Percentile Values for BMI-for-Age
Age
(Yrs. and Mos.)
BMI
2.0 to 2.1 14.5
2.2 to 2.4 14.4
2.5 to 2.7 14.3
2.8 to 2.11 14.2
3.0 to 3.2 14.1
3.3 to 3.6 14.0
3.7 to 3.11 13.9
4.0 to 4.5 13.8
4.6 to 5.0 13.7
5.1 to 6.0 13.6
6.1 to 7.6 13.5
7.7 to 8.6 13.6
8.7 to 9.1 13.7
9.2 to 9.6 13.8
9.7 to 9.11 13.9
10.0 to 10.3 14.0
10.4 to 10.7 14.1
10.8 to 10.10 14.2
10.11 to 11.2 14.3
11.3 to 11.5 14.4
11.6 to 11.8 14.5
11.9 to 11.11 14.6
12.0 to 12.1 14.7
12.2 to 12.4 14.8
12.5 to 12.7 14.9
12.8 to 12.9 15.0
12.10 to 13.0 15.1
Age
(Yrs. and Mos.)
BMI
13.1 to 13.2 15.2
13.3 to 13.4 15.3
13.5 to 13.7 15.4
13.8 to 13.9 15.5
13.10 to 13.11 15.6
14.0 to 14.1 15.7
14.2 to 14.4 15.8
14.5 to 14.6 15.9
14.7 to 14.8 16.0
14.9 to 14.10 16.1
14.11 to 15.0 16.2
15.1 to 15.3 16.3
15.4 to 15.5 16.4
15.6 to 15.7 16.5
15.8 to 15.9 16.6
15.10 to 15.11 16.7
16.0 to 16.1 16.8
16.2 to 16.3 16.9
16.4 to 16.5 17.0
16.6 to 16.8 17.1
16.9 to 16.10 17.2
16.11 to 17.0 17.3
17.1 to 17.2 17.4
17.3 to 17.5 17.5
17.6 to 17.7 17.6
17.8 to 17.9 17.7
17.10 to 17.11 17.8
Form SSA-4815 (01-2017) UF Page 9 of 9
Table 4 - Females Age 2 to Attainment of Age 18 - Third Percentile Values for BMI-for-Age
Age
(Yrs. and Mos.)
BMI
2.0 to 2.2 14.1
2.3 to 2.6 14.0
2.7 to 2.10 13.9
2.11 to 3.2 13.8
3.3 to 3.6 13.7
3.7 to 3.11 13.6
4.0 to 4.4 13.5
4.5 to 4.11 13.4
5.0 to 5.9 13.3
5.10 to 7.6 13.2
7.7 to 8.4 13.3
8.5 to 8.10 13.4
8.11 to 9.3 13.5
9.4 to 9.8 13.6
9.9 to 10.0 13.7
10.1 to 10.4 13.8
10.5 to 10.7 13.9
10.8 to 10.10 14.0
10.11 to 11.2 14.1
11.3 to 11.5 14.2
11.6 to 11.7 14.3
11.8 to 11.10 14.4
11.11 to 12.1 14.5
12.2 to 12.4 14.6
Age
(Yrs. and Mos.)
BMI
12.5 to 12.6 14.7
12.7 to 12.9 14.8
12.10 to 12.11 14.9
13.0 to 13.2 15.0
13.3 to 13.4 15.1
13.5 to 13.7 15.2
13.8 to 13.9 15.3
13.10 to 14.0 15.4
14.1 to 14.2 15.5
14.3 to 14.5 15.6
14.6 to 14.7 15.7
14.8 to 14.9 15.8
14.10 to 15.0 15.9
15.1 to 15.2 16.0
15.3 to 15.5 16.1
15.6 to 15.7 16.2
15.8 to 15.10 16.3
15.11 to 16.0 16.4
16.1 to 16.3 16.5
16.4 to 16.6 16.6
16.7 to 16.9 16.7
16.10 to 17.0 16.8
17.1 to 17.3 16.9
17.4 to 17.7 17.0
17.8 to 17.11 17.1
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Ssa-4815 Medical Report On Child Wtih Allegation Of Human Immunodeficiency Virus (HIV) Infection

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Completed 6 May 2020

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