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

Form Approved
OMB No . 0960 - 0500

SOCIAL SECURITY ADMINISTRATION

FO CODE:

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 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 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 ADDRESS

CLAIMANT'S PHONE NUMBER

-

(

)

-

-

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.

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

10.

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

11.

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

12.

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

13.

MUCORMYCOSIS

14.

2.

PULMONARY TUBERCULOSIS, resistant to
treatment

3.

NOCARDIOSIS

4.

SALMONELLA BACTEREMIA, recurrent non-typhoid

PNEUMOCYSTIS PNEUMONIA OR
EXTRAPULMONARY PNEUMOCYSTIS
INFECTION

5.

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

PROTOZOAN OR HELMINTHIC INFECTIONS

6.

7.

In a child less than 13 years of age, MULTIPLE OR
RECURRENT PYOGENIC BACTERIAL INFECTION(S) 15.
of the following types: sepsis, pneumonia, meningitis,
bone or joint infection, or abscess of an internal organ or
body cavity (excluding otitis media or superficial skin or
16.
mucosal abscesses) occurring 2 or more times in 2 years
MULTIPLE OR RECURRENT BACTERIAL
INFECTION(S), including pelvic inflammatory disease,
requiring hospitalization or intravenous antibiotic
treatment 3 or more times in 1 year

FUNGAL INFECTIONS
8.

ASPERGILLOSIS

9.

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

Form SSA-4815-F6 (04-2012) ef (04-2012) Destroy Prior Editions

17.

CRYPTOSPORIDIOSIS, ISOSPORIASIS, OR
MICROSPORIDIOSIS, with diarrhea lasting for
1 month or longer
STRONGYLOIDIASIS, extra-intestinal
TOXOPLASMOSIS of an organ other than the liver,
spleen, or lymph nodes

VIRAL INFECTIONS
18.

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

19.

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
Page 1

20.

21.

22.

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

32.

IMPAIRED BRAIN GROWTH (acquired
microcephaly or brain atrophy)

33.

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

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

MALIGNANT NEOPLASMS

GROWTH DISTURBANCE WITH:
34.

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

35.

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
INVOLUNTARY WEIGHT LOSS GREATER THAN 10
PERCENT OF BASELINE that persists for 2 months or
longer

23.

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

24.

KAPOSI'S SARCOMA, with extensive oral lesions; or
involvement of the gastrointestinal tract, lungs, or other
36.
visceral organs; or involvement of the skin or mucous
membranes with extensive fungating or ulcerating
lesions not responding to treatment

25.

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

26.

SQUAMOUS CELL CARCINOMA OF THE ANAL
CANAL OR ANAL MARGIN

37.

DIARRHEA
38.

SKIN OR MUCOUS MEMBRANES
27.

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)

HEMATOLOGIC ABNORMALITIES
28.

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.

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

30.

THROMBOCYTOPENIA, with platelet counts
3
40,000/mm or less despite prescribed therapy, or
recurrent upon withdrawal of treatment; or platelet
3
counts repeatedly below 40,000/mm 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.

LOSS OF PREVIOUSLY ACQUIRED, OR MARKED
DELAY IN ACHIEVING, DEVELOPMENTAL
MILESTONES OR INTELLECTUAL ABILITY
(including the sudden onset of a new learning
disability)

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

CARDIOMYOPATHY
39.

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

PULMONARY CONDITIONS
40.

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

NEPHROPATHY
41.

NEPHROPATHY, resulting in chronic renal failure

INFECTIONS RESISTANT TO TREATMENT OR
REQUIRING HOSPITALIZATION OR INTRAVENOUS
TREATMENT 3 OR MORE TIMES IN 1 YEAR
42.

SEPSIS

43.

MENINGITIS

44.

PNEUMONIA (non-PCP)

45.

SEPTIC ARTHRITIS

46.

ENDOCARDITIS

47.

SINUSITIS, radiographically documented

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Page 2

SSA will insert the following revised Privacy Act 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 of
eligibility for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. 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 complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0089, entitled, Claims Folders
System; and, 60-0103, entitled, Supplemental Security Income Record and Special Veterans
Benefits. Additional information about these and other system of records notices and our
programs is available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs 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.

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.

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.

D. OTHER MANIFESTATIONS OF HIV INFECTION
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 LIMITATION(S). COMPLETE ONLY THE ITEMS FOR THE CHILD'S PRESENT
AGE GROUP.
b. BIRTH TO ATTAINMENT OF AGE 1 - Any of the following:
1.

2.

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

3.

APATHY, OVER-EXCITABILITY, OR FEARFULNESS, demonstrated by an absent or grossly excessive
response to visual stimulation, auditory stimulation, or tactile stimulation; or

4.

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.

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 (i.e., cognitive/communicative, motor, and social).

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

GROSS OR FINE 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.
4.

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

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.

Marked impairment in age-appropriate SOCIAL FUNCTIONING (considering information from parents or
other individuals who have knowledge of the child, when such information is needed and available); or

3.

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); or

4.

DEFICIENCIES OF CONCENTRATION, PERSISTENCE, OR PACE resulting in frequent failure to
complete tasks in a timely manner.

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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-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 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. 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's
parent or guardian 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. Complete only the areas of functioning 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 of functioning 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.a)
"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
shown 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).
WHAT WE MEAN BY "MARKED": (See Item 48.d - Applies only to Children Age 3 to 18)
• 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 (04-2012) ef (04-2012) Destroy Prior Editions

`

Privacy Act Statement
See Revised Privacy Act
Collection and Use of Personal Information
Statement and PRA
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.
Paperwork Reduction 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 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.

Form SSA-4815-F6 (04-2012) ef (04-2012) Destroy Prior Editions