Form SSA-4814-F5 Medical Report on Adult with Allegation of Human Immunod

Form Approved
OMB No. 0960-0500

SOCIAL SECURITY ADMINISTRATION

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

CLAIMANT'S SIGNATURE (Required only if Form SSA-827 is NOT attached)

A. IDENTIFYING INFORMATION
CLAIMANT'S NAME

CLAIMANT'S ADDRESS

CLAIMANT'S PHONE NUMBER

CLAIMANT'S SSN

(

-

)

-

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. OPPORTUNISTIC AND INDICATOR DISEASES: Please check if applicable.
BACTERIAL INFECTIONS
1.

2.

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

11.

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

12.

MUCORMYCOSIS

13.

PNEUMOCYSTIS PNEUMONIA OR
EXTRAPULMONARY PNEUMOCYSTIS
INFECTION

PULMONARY TUBERCULOSIS, resistant to
treatment

3.

NOCARDIOSIS

4.

SALMONELLA BACTEREMIA, recurrent non-typhoid

5.

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

6.

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

PROTOZOAN OR HELMINTHIC INFECTIONS
14.

CRYPTOSPORIDIOSIS, ISOSPORIASIS, OR
MICROSPORIDIOSIS, with diarrhea lasting for
1 month or longer

15.

STRONGYLOIDIASIS, extra-intestinal

16.

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

VIRAL INFECTIONS
17.

CYTOMEGALOVIRUS DISEASE, at a site other than
the liver, spleen, or lymph nodes

18.

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.

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

20.

PROGRESSIVE MULTIFOCAL
LEUKOENCEPHALOPATHY

FUNGAL INFECTIONS
7.

ASPERGILLOSIS

8.

CANDIDIASIS involving the esophagus,
trachea, bronchi, or lungs, or at a site other
than the skin, urinary tract, intestinal tract, or
oral or vulvovaginal mucous membranes

9.

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

10.

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

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21.

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

31.

MALIGNANT NEOPLASMS
22.

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

23.

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

24.

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

25.

SQUAMOUS CELL CARCINOMA OF THE ANAL
CANAL OR ANAL MARGIN

HIV WASTING SYNDROME
32.

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)

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

DIARRHEA
33.

SKIN OR MUCOUS MEMBRANES
26.

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

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

CARDIOMYOPATHY
34.

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

NEPHROPATHY
HEMATOLOGIC ABNORMALITIES
27.

28.

29.

ANEMIA (hematocrit persisting at 30 percent or
less), requiring one or more blood transfusions on
an average of at least once every 2 months
GRANULOCYTOPENIA, with absolute neutrophil
3
counts repeatedly below 1,000 cells/mm and
documented recurrent systemic bacterial infections
occurring at least 3 times in the last 5 months
THROMBOCYTOPENIA, with 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 ABNORMALITIES
30.

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

35.

NEPHROPATHY, resulting in chronic renal failure

INFECTIONS RESISTANT TO TREATMENT OR
REQUIRING HOSPITALIZATION OR INTRAVENOUS
TREATMENT 3 OR MORE TIMES IN 1 YEAR
36.

SEPSIS

37.

MENINGITIS

38.

PNEUMONIA (non-PCP)

39.

SEPTIC ARTHRITIS

40.

ENDOCARDITIS

41.

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.
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D. OTHER MANIFESTATIONS OF HIV INFECTION
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., severe fatigue, fever, malaise, involuntary weight loss, pain, night sweats, nausea, vomiting, headaches,
or insomnia).
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:

NO. OF EPISODES IN
THE SAME 1-YEAR PERIOD:

DURATION
OF EACH EPISODE:

3

1 month each

EXAMPLE: Diarrhea

AND
b. ANY OF THE FOLLOWING:
Marked limitation of ACTIVITIES OF DAILY LIVING; or
Marked limitation in maintaining SOCIAL FUNCTIONING; or
Marked limitation 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

FOR
OFFICIAL
USE
ONLY

FIELD OFFICE DISPOSITION:
DISABILITY DETERMINATION SERVICES DISPOSITION:

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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 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 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.
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 COMPLETE 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 of the functional limitations imposed by the illness; we just need to know whether
your patient's ability to function has been affected to a "marked" degree in any of the areas listed. See below for an
explanation of the term "marked."
SPECIAL TERMS USED IN SECTION D
WHAT WE MEAN BY "REPEATED" MANIFESTATIONS OF HIV INFECTION: (See Item 42.a)
"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 occurs 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, pancreatitis, hepatitis, peripheral neuropathy,
glucose intolerance, muscle weakness, cognitive or other mental limitation).
• Manifestations of HIV must result in significant, documented, symptoms and signs (e.g., severe fatigue, fever, malaise,
involuntary weight loss, pain, night sweats, nausea, vomiting, headaches, or insomnia).
Continued on the reverse
Form SSA-4814-F5 (10-2009) ef (10-2009)

WHAT WE MEAN BY "MARKED" LIMITATION 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 limitation in 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 limitation in completing tasks.

Privacy Act Statement
Collection and Use of Personal Information

See revised Privacy Act
Sections 205(a), 223(d), and 1633(e)(1) of the Social Security Act, as amended, authorize
us to collect this
Statement
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
revised
regarding this form, routine uses of information, and our See
programs
and PRA
systems, is available on-line at www.ssa.gov
or at your local 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 (10-2009) ef (10-2009)

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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. We will use the information you provide to make a
determination on a claimant’s disability claim.
The information you furnish on this form is voluntary. However, failure to provide us
with the requested information could prevent us from making 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, including but 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.
A complete list of routine uses for this information is available in our System of Record
Notice entitled, the Master Beneficiary Record (60-0090). Additional information about
this and other systems of records notices and our programs are available from our Internet
website at www.socialsecurity.gov or at your local Social Security office.

SSA will insert the following revised PRA Statement 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 (OMB) control number. The OMB control number for this
collection is 0960-0500. We estimate that it will take between 10 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.