SSA-4814-F6 Current Version

Form Approved
OMS No. 0960'()500

SOCIAL SECURITY ADMINISTRATION

DOIBO CODE:

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

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

o Form SSA-827, "Authorization to Release Medical Information to the Social Security Administration." attached.

o Iagency
hereby authorize the medical source named below to release or disclose to the Social Security Administration or State.
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 ADDRESS

GLAIMANT'S DATE OF BIRTH MEDICAL SOURCE'S NAME

B. HOW WAS HIV INFECTION DIAGNOSED?

o Laboratory testing confirming HIV infection

CLAIMANT'S PHONE NUMBER

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

C. OPPORTUNISTIC AND INDICATOR DISEASES: Please check if applicable.
BACTERIAL INFECTIONS
1.0 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
2. 0

PULMONARY TUBERCULOSIS, resistant to

treatment

3. 0 NOCARDIOSIS
4. 0 SALMONELLA BACTEREMIA, recurrent non-typhoid

11. 0 HISTOPLASMOSIS, at a site other than the lungs or
lymph nodes
12. 0 MUCORMYCOSIS
PROTOZOAN OR HELMINTHIC INFECTIONS
13. 0 CRYPTOSPORIDIOSIS. ISOSPORIASIS. OR
MICROSPORIDIOSIS, with diarrhea lasting for
1 month or longer
14. 0 PNEUMOCYSTIS CARINII PNEUMONIA OR
EXTRAPULMONARY PNEUMOCYSTIS
CARINIIINFECTION

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

15. 0 STRONGYLOIDIASIS, extra-intestinal

6. 0

16.0 TOXOPLASMOSIS, of an organ other than the liver,
spleen, or lymph nodes

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

7. 0 ASPERGILLOSIS
8. 0 CANDIDIASIS, at a site other than the skin.

urinary tract, intestinal tract, or oral or

vulvovaginal mucous membranes; or

candidiasis involving the esophagus, trachea,

bronchi. or lungs

9. 0 COCCIDIOIDOMYCOSIS. at a site other than

the lungs or lymph nodes

10. 0 CRYPTOCOCCOSIS, at a site other than the
lungs (e.g., cryptococcal meningitis)

.

Form SSA·4814-F5 (5-2000) ef (12-2007) Destroy Prior Editions

VIRAL INFECTIONS
17. 0 CYTOMEGALOVIRUS DISEASE, at a site other than
the liver, spleen. or lymph nodes
18. 0 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
19.0 HERPES ZOSTER, disseminated or with
multidermatomal eruptions that are resistant to
treatment
20. 0 PROGRESSIVE MULTlFOCAL
LEUKOENCEPHALOPATHY
'Page 1

21.0 HEPATITIS, resulting in chronic liver disease

31.0 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

manifested by appropriate findings (e.g., persistent
ascites, bleeding esophageal varices, hepatic
encephalopathy)

MALIGNANT NEOPLASMS
22.
23.

24.

0

0

0

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

HIV WASTING SYNDROME
32. 0 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

LYMPHOMA of any type (e.g., primary lymphoma of
the brain, Burkitt's lymphoma, immunoblastic
sarcoma, other non-Hodgkins lymphoma, Hodgkin's
disease)

25. 0 SQUAMOUS CELL CARCINOMA OF THE ANUS

DIARRHEA
SKIN OR MUCOUS MEMBRANES

3.3. 0 DIARRHEA. lasting for 1 month or longer, resistant to
treatment, and requiring intravenous hydration,
intravenous alimentation, or tube feeding

26. 0 CONDITIONS OF THE SKIN OR MUCOUS

MEMBRANES, with extensive fungating or
ulcerating lesions not responding to treatment (e.g.,
dermatological conditions such as ecz,ema or
psoriasis. vulvovaginal or other mucosal candida.
condyloma caused by human papillomavirus. genital
ulcerative disease)

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

HEMATOLOGIC ABNORMALITIES
27.

0

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. 0 GRANULOCYTOPENIA, with absolute neutrophil

counts repeatedly below 1.000 cellslmm 3 and
documented recurrent systemic bacterial infections
occurring at least 3 times in the last 5 months

29.

0

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

NEPHROPATHY
35.0 NEPHROPATHY, resulting in chronic renal failure

INFECTIONS RESISTANT TO TREATMENT OR

REQUIRING HOSPITALIZATION OR INTRAVENOUS

TREATMENT 3 OR MORE TIMES IN 1 YEAR

36.0 SEPSIS
37.

0

MENINGITIS

38.0 PNEUMONIA (non-PCP)
39.0 SEPTIC ARTHRITIS

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

40.

0

ENDOCARDITIS

41: 0 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.

Form SSA-4814-F5 (5-2000) et (12-2007)

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D. OTHER MANIFESTA'nONS OF HIV INFEC1"ION
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., fatigue. fever. malaise, weight loss. pain. night sweats).

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:

b.

NO. OF EPISODES IN

DURATION

ANY OF THE FOLLOWING:

o Marked restriction of ACTIVITIES OF DAILY LIVING; or

o Marked difficulties in maintaining SOCIAL FUNCTIONING; or
o Marked difficulties 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 or misleading statement about a material fact in this
Information, or causes someone else to do so, commits a crime and may be sent to prison, or may face
other penalties, or both.

G.SIGNATURE AND TITLE (e.g., physician, R.N.) OF PERSON COMPLETING THIS FORM

.....

Form SSA-4814·F5 (5·2000) ef (12·2007)

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 HlV 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. Ifthe 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 COM PLETE 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 ofthe functional limitations imposed by the illness; wejust need to know whether your patient's
ability to function has been affected to a "marked" degree in any ofthe areas listed. See below for an explanation ofthe term "marked.

"

SPECIAL TERMS USED IN SECTION D
WHAT WE MEAN BY "REPEATED" MANIFESTATIONS OF HIV INFECTION: (See Item 42&)
"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 oecurs 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).
Manifestations of HIV must result in significant. documented, symptoms and signs (e.g., fatigue, fever, malaise. weight loss, pain, night
sweats),

Continued on the reverse
Form SSA-4814-F5 (5-2000) ef (12-2007)

WHAT WE MEAN BY "MARKED" LIMITATION OR RESTRICTION 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 difficulty 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 difficulty completing tasks.

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS:
The Social Security Administration is authorized to collect the information on this form under sections 205(a), 223(d) and
I 633(e)(l) of the Social Security Act. The information on this form is needed by Social Security to make a decision on the
named claimant's claim. While giving us the information on this form is voluntary, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named claimant's claim. Although the information
you furnish is almost never used for any purpoSe other than making a determination about the claimant's disability, such
information may be disclosed by the Social Security Administration as follows: (I) to enable a third party or agency to assist
Social Security in establishing rights to Social Security benefits andlor coverage; (2) to comply with Federal laws requiring the
release of information from Social Security records (e.g., to the Government Accountability Office and the Department of
Veterans Affairs); and (3) to facilitate statistical research and audit activities necessary to assure the integrity and improvement
of the Social Security Programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).
We may also use the information you give us when we match records by computer. Matching programs compare our records
with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove
that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available in Social
Security offices. If you want to learn more about this, contact any 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 control number. We estimate that it will take about 10 minutes to read the instructions,
gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. To find the nearest office, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). Send
only comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Form SSA-4814-F5 (5-2000) af (12-2007)