Form SSA-4815-F6 Medical Report on Child with Allegation of Human Immunod

fonn Ap"""",,,
0". No. 09I10-0500

SOCIAl. SECURITY ADMINISTRATION

DOIBO CODE:

MEDICAl REPORT ON CHILD WITH ALLEGATION OF
HUMAN IMMUNODEFICIENCY VIRUS (HIVIINFECnON

The Individual named below has flied an application for a period of ....blllty and/or diHbiIity payments. If you complete this
form. your patient may be able to receive early payments. IThIs Is not a request for an examination. but for existing medical
Information.'
MEDICAl RElEASE INFORMATION
D Form SSA-827. ·Authorlzation to Release Medlcallnformatlon to the Social Security Administration: attached.
D 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 tre8tment for humen immunodeficiency virus IHIV)
infection.
DATE

CLAIMANT'S PARENT'S OR GUARDIAN'S SIGNATURE I./Iequbed only If Form SSA-827 Is NOT IIttIIt:MdJ

A. IDENTIFYING INFORMAnON
CLAlMANl'S NAME

CLAIMANT'S PHONE NUMBER

CLAIMANT'S SSM

)
CLAIMANT'S ADDRESS

MEDICAL SOURCE'S NAME

CLAIMANT'S DATE OF BIRTH

/

/

B. HOW WAS HIV INFECTION DIAGNOSED?

o Infec1ion
Laboratory testing confirming HIV

o and
Other
I~"'tory fllldings. medical history.
dlagnoslsl..) indicated in the medical evidence .
clinical and

C. OPPORTUNISTIC AND INDICATOR DISEASES: I'teIItIs check H IIppllcllble.
BACTERIAL INFECTIONS
1.

0 MYCOBACTERIAl INFECTION le.g., caused by
M. avium-lntracellulere. M. kanaasi, or
M. tuberculosis). at a site other than
the lungs. skin. or cervical or hilar lymph
nodes

2. 0 PULMONARY TUBERCULOSIS. resistant to
treatment

0 NOCARDIOSIS
4. 0 SALMONELLA BACTEREMIA. recurrent non-typhoid
5. 0 SYPHIUS OR NEUROSYPHILIS (e.g ••
3.

meningovascular syphilis) reaultlng In neurologic or
other sequelae

6. D In a child less than 13 years of age. MULTIPLE OR
RECURRENT PYOGENIC BACTERIAlINFECTION(S)
of the folowlng types: sepsis, pneumonia,
meningitis. bone or joint infection, or abscess of an
intamal organ or body cevity (excluding otitis media
or superficial skin or mucosal abscessesl occurring
2 or more times in 2 years

7. D MULTIPLE OR RECURRENT BACTERIAl

INFEC11ONIS). including pelvic inflammatory
disease. requiring hospitalization or Intravenous
antibiotic treatment 3 or more times in 1 year
FUNGAL INFECTIONS

8.

10. 0 COCCIDIOIDOMYCOSIS, at a site other than the

lunge or lymph nodes

, ,. 0 CRYPTOCOCCOSlS, at a site other than the lungs

(e.g., cryptococca' meningitis)

12. 0 HISTOPLASMOSIS. at a site other than the lungs or

lymph nodes

13. 0 MUCORMYCOSIS
14!

0 PNEUMOCvSTIS PNEUMONIA OR EXTRAPULMONARY
PNEUMOCYSTIS INFECOON

PROTOZOAN OR HELMINTHIC INFECTIONS
15
.

O!. CRvPrOSPORID.oSlS.
ISOSPORlASIS, OR
MICROSPORIDIOSIS.
diarrhea lasting for 1
month or longer

16.. 0 STRONGYLOIDIASIS. extra-intestinal
17. 0 TOXOPLASMOSIS of an organ other than the liver.

spleen. or lymph nodes

VIRAL INFECTIONS

18. D CYTOMEGALOVIRUS DISEASE. at a site other than

the liver. spleen, or lymph nodes

19. D HERPES SIMPLEX VIRUS caU8ing mucocutaneous

D ASPERGILLOSIS

9. 0 CANDIDIASIS involving the esophagus, trachea, bronchi,
or lungs, or at a site other than the skin, urinary tract,
• 20
ral
I """;na1 mucous membranes'

,ID~I.na!.........
_ .. ~... or 0

.

or vu vo......

~

Form SSA-4815-F6101-2001) EF 107-2005)

with

0

Destroy Prior Editions

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

disseminetad infection

HERPES ""OSTER d'
. ated
It'h
" ' . I8semln
or w

multidermetomal eruptions that are resistant to
treatment

Page 1

21.

0

PROGRESSIVE MULTIFOCAl
LEUKOENCEPHAlOPATHY

22.

0

HEPATITIS, resulting in chrooic liver disease
manifested by appropriate findings le.g., persistent
ascites, bleeding esophageal varices, hepatic
encephalopathy)

33.

0

GROWTH DISTURBANCE WITH:
34.

0

INVOWNTARY WEIGHT LOSS lOR FAILURE TO
GAIN WEIGHT AT AN APPROPRIATE RATE FOR'
AGE) RESULTING IN A FALL OF 15 PERCENTILES
from established growth curve (00 standard growth
charts' that persists .for 2 months or longer

35.

0

INVOLUllTARY WEIGHT LOSS 'OR FAILURE TO
GAIN WEIGHT AT AN APPROPRIATE RATE FOR
AGE) RESULUNO IN A FALL TO BB.OW THE
THIRD PERCENTILE from established growth curve
(00 standard growth cherts) thet persists for 2
months or longer
'

36.

0

INVOLUNTA"Y WEIGHT LOSS GREATER THAN 10
PERCENT OF BASELINE that persists for 2 months

MAUGNANT NEOPlASMS

0

CARCINOMA OF TH! 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 ImICOUS membreries with extensive fungating or
ulcereting lesIon8 not responding to treatment

25.

0

LYMPHOMA of any type (e.g., primary lymphoma

23.

of the brain, Burkitt's lymphoma, Immunobleatic
sarcoma, other non-Hodgkina Iy~oma, Hodgkin's
d~)

,

or longer

37.

0

26.0 SQUAMOUS CELL CARCINOMA Of THE
ANAL CANAL OR ANAL MARGIN
SKIN OR MUCOUS MJ;MBRANES
27.

0

CONDmONS OF THE SKIN OR MUCOUS
MEMBRANE$, with extensive fungating or
ulcerating IeeIons not responding to treatment (e.g.,
dermatologfcel·conditlona such as eczema or
psoriasis, ~ or other mucoeal cendida.
condyloma caUMd by human papllomavlrus, genital
ulcerative disease}

DIARRHEA
38.

30.

0

NEUROLOGICAl. MANIFESTAnONS OF ltV
INFECTION le.g., HIV ENCEPHALOPATHY,
PERIPHERAL NEUROPATHY) RESULTfNG IN:

40.

0

32. 0 IMPAIRED BRAIN GROWTH (acquired microcephaly
or brain atrophy)

Form SSA-4816-F6 (01-2001) EF (07·20051

LYMPHOID INTERSTITIAL
PNEUMONIAIPULMONAY LYMPHOID
HYPERPtAstA ILIPIPLH complex), with respiratory
symptoms that significantly interfere with
age-appropriate activities, and that cannot ba
controlled by prescribed treatment

NEPHROPATHY
41.

0

NEPHROPATHY, resulting In chronic renal failure
INFECTIONS RESISTANT TO TREATMENT OR

REQUIRING HOSPITAUZATfON OR INTRAVENOUS
TREATMENT 3 OR MORE TIMES IN I YEAR
42.

43.
31.0 LOSS OF PREVIOUSLY ACQUIRED. OR MARKED \
DELAY IN ACHIEVING,DEVELOPMENTAL
'44.
MILESTONES OR INTELLECfUAL ABlLrrY

(including the sudden onset ofa new learning disability)

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

PULMONARY CONDITIONS

0 THROM~OPENIA, with platalet counts of

4O,oootmm or lesa despite presorlbed therapy, or
recurrent upon withdrewal Clf treatmTt; or platelet
counts repeatedly below 4O,OOO/mm with at least
one spontaneous hemorrhage, requiring transfusion
in the last 5 months: or Intracrenial bleeding in the
last 12 months

DIARRHEA. lasting 'for 1 month or longer, resistant

CARDIOMYOPATHY

ANEMIA (h~tDCrit pereistlng at. 30 percent or
leesl, requiring one or more blood transfusions 00
en average of at least once every 2 months

29.. 0 GRANULOCYTOPENIA. with absolute ""!Itrophil
coun1B repeatedly below 1,000 cellslmm and
documented recurrent systemic bacterial Infections
occurring at least 3 times in the last 5 months

0

to treatment. and requiring intravenous hydration,
intravenous alimentation, or tube feeding

39.

0

GROWTH IMPAIRMENT, with fall of greater than
15 percentiles in height which Is sustained; or fall
to, orpensiatence of, height below the third
percentile

HEMATOLOGIC ABNORMAUnES
28.

PROGRESSIVE MOTOR DYSFUNCTION effecting
galt and station or flne and gross motor skills

0
0

0
0

,45.
46.

47.

SEPSIS

MENINGITIS

.

PNEUMONIA (non-PCP}

SEPTIC ARTHRITIS

0
0

ENDOCARDITIS

SINUsmS, radiographically documented

Page 2

_it

NOTE: If you have chealced any of the boxu In section C, proceed to IIIICtIoIt E to
.ny t.m.rks you wtsh to
make about this patient's condition. Then, proceed to sections F and G and . . . and date the fonn.

If'YQ\.! hllVe not ohacked1tlly of the box.. In section C. please cornPlate ...... 1,). Ste part VI ,of the instruction .
"'fOt;deJI~;4f1he • • WI use.., ~D. ~ to·~iJf.(y,t)Q1h4i."'~ you wish •
~m" ~1iu~!'At's ~. 1tferI~ prCJCeedto aeCtlol1s FII'Ki G ~,~·dtill ...·fO!'tll.

D. OTHER MANIFESTATIONS OF HIV INFECTION
48.

a.

ANY MANIFESTATlONtS) OF HIV INFECTION INCLUDING ANY DISEASES USTED IN SECTION C, items 1-47,
but without the specified findings described above, or any other manlfestationja) of HIV infection; please
specify type of manifestation Is):

AND ANY OF THE FOLLOWING RJNCTIONAL L1MITATlON(S). COMPlETE ONLY THE ITEMS FOR THE CHILD'S PRESENT
AGE GROUP.
b. B1~ TO ATTAINMENT OF AGE " - Any of the following:
,. COQNITIYE/COMMUNICATIVE RJNCTIONINQ 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

3.

0

4.

0

5.

0

age;

Or

APATHY. OVER-EXClTABILITY,OR FEARFULNESS. demonstrated by an absent or grossly excessive
ruponae to visual stimulation, auditory atimulatlon, or tactile stimulation; or
FAILURE TO SUSTAIN IOCIAl.INTERACTION on an ongoing, raclprocal basis as evidenced by inability by
6 months to participate In vocal, visual, end motoric exchanges (Including' facial expressional; or failure by
9 months to communicate ba!Nc emotional response., such as cuddling or exhibiting protest or enger; or
failure to attend to the cereglver's voice or face or to explore an Inanimate object for a period of time
appropriate to the infant',s age; or
ATTAINMENT OF DEVB.OPMENT OR FUNCTION generaly acquired by children no more than two-thirds
of the child's chronological age In two or more areas (j.e., cognitive/communicative, motor. and socia/).

c. AGE' TO ATTAINMENT OF AGE 3 - Any of the following:
1.
GROSS OR ANE MOTOR DEVELOPMENT at a level generally acquired by children no more than one-half
the child's chronological age; or
2.
COGNITIVE/COMMUNICATIVE 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 OEVaOPMENT OR FUNCTION generally acquired by children no more than two-thirds
of the child's chronological age in two or more ereas covered by " 2. or 3.

0
0

d. AGE 3 TO ATTAINMENT OF AGE '8 - Umitation In at least two of the following areas:
,. 0 Marked impairment in age-approprlate COGNmVEfCOMMUNICATlVE FUNCTION (considering historical
and other Information from parents or other Individual. who have knowledge of the child, when such
'
Information Is needed and availabla); or
2. 0 Marked impeirment In age-appropriate SOCIAL RJNCTIONING (considering information from parents or
other Individuala who have knowledge of the child, when such information Is needed and available); or
3. 0 Marked impairment In PERSONAL FUNCTIONING 118 evidenced by marked restriction of age-appropriate
activities of daily living (conaidering information from parents or other individuals who have knowledge of
the child, when such information is needed end available).
4. 0 DEFICIENCIES OF CONCENTRATION. PERSISTENCE, OR PACE resulting in frequent failure to complate
tesks in a timely manner.

Form SSA-4815-F6 (01-2001) EF (07-2005)

Page 3

E. REMARKS:

IPlease use this space if you lack sufficient room in section D or to provide any other comments you wish
about your patient.)

TELEPHONE NUMBER IArsa Code)

F. MEDICAL SOURCE'S NAME AND ADDRESS (Print or ryp.'

DATE

I declare

uncar

statementaorf~.

..

at ~ ttn.t,. fiRe ~. ai, ""tD~ oatfils !ftJ.$l,
_ . .IS . . . _'.~ct tattie ,*"111 my know"".

.1Itid· tin ahY

accompanying

··;.t

G. SIGNATURE AND TmE 'e.g•• ph\fIIIcIM. R.N.I OF PERSON COMPLE11NG THIS FORM

foR
OfFICIAL

USE
ONLY

Form SSA-4815-F6101·2001l EF 107·2005)

Page 4

<.

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 HIV infection. MEDICAl SOURCE: Please detach this instruction sheet and use it to cOlJlplete
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 evidimce needed to
process your patient's claim.
II. WHO MAY COMPLETE THIS FORM:
A physician. nurse, or other member of a hospitsl 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 Ian 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 raeelve 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 ell of the sections on the form.
• AlWAYS COMPlETE SECTION B.
• COMPLETE SECllON 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 ITEI/IIN SECTION C. See the spacial 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. NOTE: This form Is not complete until It Is signed.
V. HOW TO REruM 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 petient without a return envelope, give the completed. signed form back to your
patient's parent or guardian for nnum 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 manifeetstions of HIV your patient may have. It also asks you to give us an
idea of how your patient's ability to function hes been affacted. Complete only the areas of functioning appliceble
to the child's age group.
• We do not need detailed descriptions of the functionallimitstions imposed by the illness; we just need to know
whether your patient's ability to function hes been affected to the extent described.
• For chlldran age 3 to attainment of age 18, the child must have a "marked" restriction of functioning in two areas to
be eligible for these payments. See below for
explanation of the term "marked.·

an

SPECIAl TERMS USED IN SECTION D
WHAT WE MEAN BY "MANIFESTATIONS OF HIV INFECTION": (See Item 4B.1Il
"Manifestations of HIV infection" may Include:
Any condition listed In section C, but without the findings specified there (e.g •• oral candidiasis not meeting the
criteria show in item 27 of the form. 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).

Continued on the reverse
Form SSA-4816-F6101-20011 EF (07-2005)

WHAT WE MEAN BY RMARKED w

:

(See Item 4B.d - ApplIN DnIy tD ChiIdnm Age 3 to rB)

• 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 totaUy 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.

See revised Privacy Act and Paperwork Reduction Act Statements below.
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS:
The Social Security Admlniatration is authorized to collect the information on this form under sections 205(a), 223(d) and
16331e)!1) 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 informetion 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 ciaimant'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: 11) to enable a third party or
agency to assist Social Security in establishing rights to Socisl Security benefits andlor coverage; 12) to comply with
Federal laws requiring the relNse of Information from Socisl Security records (e.g., to the General Accounting Office and
the Department of Veterens Affairs); and 13) to facilitate statistical research and audit activities necessary to assure the
integrity and improvement of the Social Security Programs le.g .• to the Bureau of the Census and private concerns under
contract to Social Security).
We may also use the information you give us Whan 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 leern more about this. contact any Social Security office.
PAPERWORK REDUcnON ACT: 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 unlesl!! we display a valid
Office of Management and Budget control number. We estimate thet it will take about 10 minutes to read the Instructions,
gather the facts. end answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office Is listed under U. S. Government agencies In yo.. telephone directory or you may cal Social
Security at 1-8()()"'772-121S. You may send comments on our time estimate above to: SSA. 6401 Security Blvd ••
Baltimore. MD 21235-8401. Send !!!!x..t:tHIII'IIIIIIIlIlfIIIItIng to our time tNtinuIte to th/llllddrtnttl, not the t»mp/lllted form.

Form SSA-4815-F6101-2001) EF (07-2005)

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1633(e)(1) of the Social Security Act, as amended, authorize
us to collect this information. The information you provide will be used to make a
determination on a claimant’s disability claim.
The information you furnish on this form is voluntary. However, failure to provide the
requested information could prevent an accurate or timely decision on the named
individual’s disability claim.
We rarely use the information you supply for any purpose other than for determining
eligibility. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the
following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
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 payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.