SSA-4815-F6 Current Version

Form Approved
OMB No. 0960'{)500

SOCIAL SECURITY ADMINISTRATION

DOIBOCODE:

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

The individual named below has filed an application for a period of disability andlor 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 INFORMA1'ION

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 the child's treatment for human immunodeficiency virus (HIV)
infec ·on.
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 ADDRESS

CLAIMANT'S SSN

CLAIMANT'S PHONE NUMBER

IVLAIMANT'S DATE OF BIRTH MEDICAL SOURCE'S NAME

B. HOW WAS HIV INFECTION DIAGNOSED?

o Laboratory testing confirming HIV infection

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

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

6.

0

In a child less than 13 years of age , MULTIPLE OR

RECURRENT PYOGENIC BACTERIA~ INFECTION(S)

10.0 COCCIDIOIDOMYCOSIS, at a site other than
the lungs or lymph nodes

11. 0 CRYPTOCOCCOSIS, at a site other than the
lungs (e.g., cryptococcal meningitis)

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

13. 0 MUCORMYCOSIS

PROTOZOAN OR HELMINTHIC INFECTIONS
14. 0 CRYPTOSPORIDIOSIS, ISOSPORIASIS, OR
MICROSPORIDIOSIS, with diarrhea lasting for
1 month or longer

15. 0 PNEUMOCYSTIS CARINII PNEUMONIA OR
EXTRAPULMONARY PNEUMOCYSTIS
CARINII INFECTION

of the following types; sepsis, pneumonia, meningitis.
bone or joint infection, or abscess of an internal organ or
16.0 STRONGYLOIDIASIS, extra-intestinal
body cavity (excluding otitis media or superficial skin or
mucosal abscesses) occurring 2 or more times in 2 years
17.0 TOXOPLASMOSIS, of an organ other than the liver,
spleen, or lymph nodes
7.0 MULTIPLE OR RECURRENT BACTERIAL
INFECTION(S). including pelvic inflammatory disease,
VIRAL INFECTIONS
requiring hospitalization or intravenous antibiotic
treatment 3 or more times in 1 year
18.0 CYTOMEGALOVIRUS DISEASE, at a site other than
the liver, spleen, or lymph nodes
FUNGAL INFECTIONS

8. 0

ASPERGILLOSIS

9. 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

Form SSA-4815-F6 (1-2001) ef (12-2007) Destroy Prior Editions

19. 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

20.

21.

0
0

HERPES ZOSTER, disseminated or with
multidermatomal eruptions that are resistant to
treatment

32.0 IMPAIRED BRAIN GROWTH (acquired
microcephaly or brain atrophy)

33.0 PROGRESSIVE MOTOR DYSFUNCTION affecting
gait and station or fine and gross motor skills

PROGRESSIVE MULTIFOCAL
LEUKOENCEPHALOPATHY

22.0 HEPATITIS, resulting in chronic liver disease

GROWTH DISTURBANCE WITH:

34.0 INVOLUNTARY WEIGHT LOSS (OR FAILURE TO
GAIN WEIGHT AT AN APPROPRIATE RATE FOR
AGE) RESULTING IN A FALL OF 15 PERCENTILES
from established growth curve (on standard growth
charts) that persists for 2 months or longer

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

MALIGNANT NEOPLASMS

23.

0

35.0 INVOLUNTARY WEIGHT LOSS (OR FAILURE TO
GAIN WEIGHT AT AN APPROPRIATE RATE FOR
AGE) RESULTING IN A FALL TO BELOW THE
THIRD PERCENTILE from established growth curve
(on standard growth charts) that persists for 2 months
or longer

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

24. 0 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
36.0 INVOLUNTARY WEIGHT LOSS GREATER THAN 10
membranes with extensive fungating or ulcerating.
PERCENT OF BASELINE that persists for 2 months or
lesions not responding to treatment
longer

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

37.0 GROWTH IMPAIRMENT, with fall of greater than 15
'" percentiles in height which is sustained; or fall to, or
persistence of, height below the third percentile
DIARRHEA

26.0 SQUAMOUS CELL CARCINOMA OF THE ANUS
38.

0

SKIN OR MUCOUS MEMBRANES

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

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

CARDIOMYOPATHY

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

HEMATOLOGIC ABNORMALITIES
28.

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

29. 0 GRANULOCYTOPENIA, with absolute reutrophil

40.

0

LYMPHOID INTERSTITIAL
PNEUMONIA/PULMONARY LYMPHOID
HYPERPLASIA (L1P/PLH complex), with respiratory
symptoms that significantly interfere with
age-appropriate activities, and that cannot be
controlled by prescribed treatment

counts repeatedly below 1,000 cellslmm and
documented recurrent systemic bacterial infections
occurring at least 3 times in the last 5 months
30.

0

THROMBOCYTOPENIA, with platelet counts
repeatedly below 40,OOO/mm 3 or less despite
prescribed therapy. or recurrent upon withdrawal of
treatment; or platelet counts repeatedly below
40.000/mm 3 with at least one spontaneous
hemorrhage, requiring transfusion in the last 5
months; or intracranial bleeding in the last 12
months

NEUROLOGICAL MANIFESTATIONS OF HIV

INFECTION (e.g., HIV ENCEPHALOPATHY,

PERIPHERAL NEUROPATHY) RESULTING IN:

31. 0 LOSS OF PREVIOUSLY ACQUIRED, OR MARKED
DELAY IN ACHIEVING, DEVELOPMENTAL
MILESTONES OR INTELLECTUAL ABILITY
(including the sudden acquisition of a new leaming
disability)
Form SSA-4815-F6 (1-2001) ef(12-2007)

NEPHROPATHY

41.0 NEPHROPATHY, resulting in chronic renal failure
INFECTIONS RESISTANT TO TREATMENT OR

REQUIRING HOSPITALIZATION OR INTRAVENOUS

TREATMENT 3 OR MORE TIMES IN 1 YEAR

42.0 SEPSIS
43.0 MENINGITIS

44.0 PNEUMONIA (non-PCP)
45·0 SEPTIC ARTHRITIS
46. 0 ENDOCARDITIS
47·0 SINUSITIS, radiographically documented
Page 2

NOTE:

If you have checked any of the boxes in section C, proceed to section E to add 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.

O. OTHER MANIFESTATIONS OF HIV INFEC1"ION
48. a. ANY MANIFESTATION(S) OF HIV INFECTION INCLUDING ANY DISEASES LISTED IN SECTION C, items 1-47,
but without the specified findings described above, or any other manifestation(s) of HIV infection; please specify type
of manifestation(s):
.

AND ANY OF THE FOLLOWING FUNCTIONAL LlMITATlON(S). COMPLETE ONLY THE ITEMS FOR THE CHILD'S PRESENT
AGE GROUP.
b. B.IRTH TO ATTAINMENT OF AGE 1 - Any ofthe following:
1.

0

COGNITIVE/COMMUNICATIVE FUNCTIONING generally acquired by children no more than one·half the
child's chronological age (e.g., in infants 0-6 months, markedly diminished variation in the production or
imitation of sounds and severe feeding abnormality, such as problems with sucking, swallowing, or
chewing); or

2.

0

MOTOR DEVELOPMENT generally acquired by children no more than one-half the child's chronological
age; or

3.0 APATHY, OVER·EXCITABILlTY, OR FEARFULNESS,

demonstrated by an absent or grossly excessive
response to visual stimulation, auditory stimulation, or tactile stimulation; or

4.0 FAILURE TO SUSTAIN SOCIAL INTERACTION on an ongoing, reciprocal basis as evidenced by inability
by 6 months to participate in vocal, visual, and motoric exchanges (including facial expressions); or failure
by 9 months to communicate basic emotional responses, such as cuddling or exhibiting protest or anger; or
failure to attend to the caregiver's voice or face or to explore an inanimate object for a period of time
appropriate to the infant's age; or
5.

0

ATTAINMENT OF DEVELOPMENT OR FUNCTION generally acquired by children no more than two-thirds
of the child's chronological age in two or more areas (Le., cognitive/communicative, motor, and social).

c. AGE 1 TO ATTAINMENT OF AGE 3 • Any of the following:
1.

0

GROSS OR FINE MOTOR DEVELOPMENT at a level generally acquired by children no more than one·half
the child's chronological age; or

2.

0

COGNITIVEICOMMUNICATlVE FUNCTION at a level generally acquired by children no more than
one-half the child's chronological age; or

3·0 SOCIAL FUNCTION

at a level generally acquired by children no more than one.half the child's

chronological age; or

4·0 ATTAINMENT OF DEVELOPMENT OR FUNCTION

generally acquired by children no more than two-thirds
of the child's chronological age in two or more areas covered by 1, 2, or 3.

d. AGE 3 TO ATTAINMENT OF AGE 18 • limitation in at least two of the following areas:

1·0 Marked impairment in age-appropriate

COGNITIVE/COMMUNICATIVE FUNCTION (considering historical
and other information from parents or other individuals who have knowledge of the child, when such
information is needed and available); or

2·0 Marked impairment in age·appropriate
3. 0

SOCIAL FUNCTIONING (considering information from parents or
other individuals who have knowledge ofthe child, when such information is needed and available); or
Marked impairment in PERSONAL FUNCTIONING as evidenced by marked restriction of age-appropriate
activities of daily living (considering information from parents or other individuals who have knowledge of
the child, when such information is needed and available).

4·0 DEFICIENCIES OF CONCENTRATION, PERSISTENCE, OR PACE resulting in frequent failure to
complete tasks in a timely manner.
Form SSA4815-F6 (1-2001) (12-2007)

Page 3

-.-----~-~----------.--~-----------

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

----~~~-~~------------

MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED SSA-4815-F6
(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 HlV 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'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.
IV. 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 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. IS.OTI;.: 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's parent or
guardian for return to the SSA field office.
VI. SPECIAL INFORMATION TO HELP YQU 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. Complete only the areas offunctioning applicable to the child's age group.
• 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 the extent described.
• For children age 3 to attainment of age 18, the child must have a "marked" restriction offunctioning in two areas to be eligible for
these payments. See below for an explanation of the term "marked."

SPECIAL TERMS USED IN SECTION D
WHAT WE MEAN BY "MANIFESTATIONS OF HIV INFECTION" (See Item 48.s)
"Manifestations of HI V infection" may include:
Any condition listed in section C, but without the findings specified there (e.g., oral candidiasis not meeting the criteria shown in item 27
of the fonn, diarrhea not meeting the criteria shown in item 38 of the form); or any other condition that is not listed in section C (e.g., oral
hairy leukoplakia, hepatomegaly).
WHAT WE MEAN BY "MARKED" (See Item 48.d - ARRlies only to Children Ale 3 to

18J

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 placed in a residential treatment facility.
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 compared to children the same
age who do not have impairments.

Continued on the reverse

Form SSA-4815-F6 (1-2001)

ef(12-2007)

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS:
The Social Security Administration is authorized to collect the infonnation on this fonn under sections 205(a), 223(d) and 1633
(e)( I) of the Social Security Act. The infonnation on this fonn is needed by Social Security to make a decision on the named
claimant's claim. While giving us the infonnation on this fonn is voluntary, failure to provide all or part of the requested
infonnation could prevent an accurate or timely decision on the named claimant's claim. Although the infonnation you furnish is
almost never used for any purpose other than making a detennination about the claimant's disability, such infonnation 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
infonnation 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 infonnation 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 infonnation 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 infonnation collection meets the requirements of 44 U.S.c. § 3507, as amended by
section 2 of the ~Qrk 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
ntu' t;ft'\~ ACttn1lllltA ~"'I"'\'UA tn· ~~" ~A{\t ~.o""11"h7 RhrA Q"l:1ttft'\"t",m "An ")1 '1"1"_~A{\l

Form SSA-4815-F6 (1-2001)

af (12-2007)