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

Form SSA-4815-BK (04-2016) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 9
OMB NO. 0960-0500
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 Disclose Information to the Social Security Administration (SSA)," 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 PHONE NUMBER

CLAIMANT'S ADDRESS

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. CONDITIONS RELATED TO HIV INFECTION: Please check if applicable.
ALL INFORMATION PROVIDED IN THIS SECTION MUST BE SUPPORTED BY DOCUMENTATION IN THE MEDICAL
RECORD. We will request your patient's medical records as part of our case adjudication process.
1. Multicentric (not localized or unicentric) Castleman
disease
Affecting multiple groups of lymph nodes

6. CD4 Count: Please indicate measurement, date recorded,
AND ordering provider

Affecting organs containing lymphoid tissue
2.

Primary central nervous system lymphoma

a. Birth to attainment of age 1:
Absolute CD4 count of 500 cells/mm3 or less

3.

Primary effusion lymphoma

4.

Progressive multifocal leukoencephalopathy

5.

Pulmonary Kaposi sarcoma

CD4 percentage of less than 15 percent
b. Age 1 to attainment of age 5:
Absolute CD4 count of 200 cells/mm3 or less
CD4 percentage of less than 15 percent
c. Age 5 to attainment of age 18:
Absolute CD4 count of 50 cells/mm3 or less

Form SSA-4815-BK (04-2016) UF

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7. Complication(s) of HIV infection requiring at least three hospitalizations within a 12-month period and at least 30 days
apart. Each hospitalization must last at least 48 hours, including hours in a hospital emergency department immediately before
the hospitalization. Complications of HIV infection may include infections (common or opportunistic), cancers, and other
conditions.
Complication of HIV Infection
Example: Diarrhea

Date of
Hospitalization
Example:
December 2, 2015

Duration

Name of Hospital

Example: 2 days

Example: Memorial Hospital

8. Neurological manifestation of HIV infection including, but not limited to, HIV encephalopathy or peripheral neuropathy,
resulting in one of the following specified impairments. Either both a and b or a and c are required.
a. Neurological manifestation (please specify):
Resulting in b. or c.
b. Each of these items requires two examinations at least 60 days apart. You must check the appropriate impairment and
fill out the table indicating the dates of examination
Loss of previously acquired developmental milestones or intellectual ability (including the sudden onset of a new
learning disability), documented on two examinations at least 60 days apart
Progressive motor dysfunction affecting gait and station or fine and gross motor skills, documented on two
examinations at least 60 days apart
Microcephaly with head circumference that is less than the third percentile for age, documented on two
examinations at least 60 days apart
DATE OF EXAMINATION

DETAILS (if applicable)

PROVIDER (if other than the person
completing form)

OR
c.

Brain atrophy, documented by appropriate medically acceptable imaging
DATE OF IMAGING

DETAILS (if applicable)

IMAGING CENTER

9. Immune suppression and growth failure. Both a and b are required.
a. CD4 count:
From birth to attainment of age 5, CD4 percentage of less than 20 percent
Please indicate measurement, date recorded, AND ordering provider

From age 5 to attainment of age 18, absolute CD4 count of less than 200 cells/mm3 or CD4 percentage of less than 14
percent. Please indicate measurement, date recorded, AND ordering provider

Form SSA-4815-BK (04-2016) UF

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b. Growth failure:
For children from birth to attainment of age 2, three weight-for-length measurements that are:
• Within a consecutive 12-month period; and
• At least 60 days apart; and
• Less than the third percentile on the appropriate weight-for-length table on pages 6-7.
DATE

LENGTH (cm)

WEIGHT (kg)

For children age 2 to attainment of age 18, three BMI-for-age measurements that are:
• Within a consecutive 12-month period; and
• At least 60 days apart; and
• Less than the third percentile on the appropriate BMI-for-age table on pages 8-9.
DATE

AGE (years and months)

BMI

D. REMARKS: (Please use this space to provide any other comments you wish about your patient.)

E. MEDICAL SOURCE'S NAME AND ADDRESS (Print or type)

TELEPHONE NUMBER
(Include 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 statement
about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or
imprisonment.
F. SIGNATURE AND TITLE (e.g., physician, R.N.) OF PERSON COMPLETING THIS FORM
FOR
OFFICIAL
USE
ONLY

FIELD OFFICE DISPOSITION:
DISABILITY DETERMINATION SERVICES DISPOSITION:

Form SSA-4815-BK (04-2016) UF

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MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED SSA-4815-BK
(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.

1. 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.

2. 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.

3. 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.

4. 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 complete at least one of the items in section C, go to section
D.
•
•

COMPLETE SECTION D IF YOU WISH TO PROVIDE COMMENTS ON YOUR PATIENT'S CONDITION(S).
ALWAYS COMPLETE SECTIONS E AND F. Note: This form is not complete until it is signed.

5. 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.

Form SSA-4815-BK (04-2016) UF

See Revised Privacy Act Statement Attached

Page 5 of 9

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.

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 about 8 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-BK (04-2016) UF

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Table 1 - Males Birth to Attainment of Age 2 - Third Percentile Values for Weight-for-Length
Length
(Centimeters)

Weight
(Kilograms)

Length
(Centimeters)

Weight
(Kilograms)

45.0

1.597

74.5

8.301

45.5

1.703

75.5

8.507

46.5

1.919

76.5

8.710

47.5

2.139

77.5

8.913

48.5

2.364

78.5

9.113

49.5

2.592

79.5

9.313

50.5

2.824

80.5

9.512

51.5

3.058

81.5

9.710

52.5

3.294

82.5

9.907

53.5

3.532

83.5

10.104

54.5

3.771

84.5

10.301

55.5

4.010

85.5

10.499

56.5

4.250

86.5

10.696

57.5

4.489

87.5

10.895

58.5

4.728

88.5

11.095

59.5

4.966

89.5

11.296

60.5

5.203

90.5

11.498

61.5

5.438

91.5

11.703

62.5

5.671

92.5

11.910

63.5

5.903

93.5

12.119

64.5

6.132

94.5

12.331

65.5

6.359

95.5

12.546

66.6

6.584

96.5

12.764

67.5

6.807

97.5

12.987

68.5

7.027

98.5

13.213

69.5

7.245

99.5

13.443

70.5

7.461

100.5

13.678

71.5

7.674

101.5

13.918

72.5

7.885

102.5

14.163

73.5

8.094

103.5

14.413

Form SSA-4815-BK (04-2016) UF

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Table 2 - Females Birth to Attainment of Age 2 - Third Percentile Values for Weight-for-Length
Length
(Centimeters)

Weight
(Kilograms)

Length
(Centimeters)

Weight
(Kilograms)

45.0

1.613

74.5

8.075

45.5

1.724

75.5

8.277

46.5

1.946

76.5

8.479

47.5

2.171

77.5

8.679

48.5

2.397

78.5

8.879

49.5

2.624

79.5

9.078

50.5

2.852

80.5

9.277

51.5

3.081

81.5

9.476

52.5

3.310

82.5

9.674

53.5

3.538

83.5

9.872

54.5

3.767

84.5

10.071

55.5

3.994

85.5

10.270

56.5

4.220

86.5

10.469

57.5

4.445

87.5

10.670

58.5

4.669

88.5

10.871

59.5

4.892

89.5

11.074

60.5

5.113

90.5

11.278

61.5

5.333

91.5

11.484

62.5

5.552

92.5

11.691

63.5

5.769

93.5

11.901

64.5

5.985

94.5

12.112

65.5

6.200

95.5

12.326

66.5

6.413

96.5

12.541

67.5

6.625

97.5

12.760

68.5

6.836

98.5

12.981

69.5

7.046

99.5

13.205

70.5

7.254

100.5

13.431

71.5

7.461

101.5

13.661

72.5

7.667

102.5

13.895

73.5

7.871

103.5

14.132

Form SSA-4815-BK (04-2016) UF

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Table 3 - Males Age 2 to Attainment of Age 18 - Third Percentile Values for BMI-for-Age
Age
(Yrs. and Mos.)

BMI

Age
(Yrs. and Mos.)

BMI

2.0 to 2.1

14.5

13.1 to 13.2

15.2

2.2 to 2.4

14.4

13.3 to 13.4

15.3

2.5 to 2.7

14.3

13.5 to 13.7

15.4

2.8 to 2.11

14.2

13.8 to 13.9

15.5

3.0 to 3.2

14.1

13.10 to 13.11

15.6

3.3 to 3.6

14.0

14.0 to 14.1

15.7

3.7 to 3.11

13.9

14.2 to 14.4

15.8

4.0 to 4.5

13.8

14.5 to 14.6

15.9

4.6 to 5.0

13.7

14.7 to 14.8

16.0

5.1 to 6.0

13.6

14.9 to 14.10

16.1

6.1 to 7.6

13.5

14.11 to 15.0

16.2

7.7 to 8.6

13.6

15.1 to 15.3

16.3

8.7 to 9.1

13.7

15.4 to 15.5

16.4

9.2 to 9.6

13.8

15.6 to 15.7

16.5

9.7 to 9.11

13.9

15.8 to 15.9

16.6

10.0 to 10.3

14.0

15.10 to 15.11

16.7

10.4 to 10.7

14.1

16.0 to 16.1

16.8

10.8 to 10.10

14.2

16.2 to 16.3

16.9

10.11 to 11.2

14.3

16.4 to 16.5

17.0

11.3 to 11.5

14.4

16.6 to 16.8

17.1

11.6 to 11.8

14.5

16.9 to 16.10

17.2

11.9 to 11.11

14.6

16.11 to 17.0

17.3

12.0 to 12.1

14.7

17.1 to 17.2

17.4

12.2 to 12.4

14.8

17.3 to 17.5

17.5

12.5 to 12.7

14.9

17.6 to 17.7

17.6

12.8 to 12.9

15.0

17.8 to 17.9

17.7

12.10 to 13.0

15.1

17.10 to 17.11

17.8

Form SSA-4815-BK (04-2016) UF

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Table 4 - Females Age 2 to Attainment of Age 18 - Third Percentile Values for BMI-for-Age
Age
(Yrs. and Mos.)

BMI

Age
(Yrs. and Mos.)

BMI

2.0 to 2.2

14.1

12.5 to 12.6

14.7

2.3 to 2.6

14.0

12.7 to 12.9

14.8

2.7 to 2.10

13.9

12.10 to 12.11

14.9

2.11 to 3.2

13.8

13.0 to 13.2

15.0

3.3 to 3.6

13.7

13.3 to 13.4

15.1

3.7 to 3.11

13.6

13.5 to 13.7

15.2

4.0 to 4.4

13.5

13.8 to 13.9

15.3

4.5 to 4.11

13.4

13.10 to 14.0

15.4

5.0 to 5.9

13.3

14.1 to 14.2

15.5

5.10 to 7.6

13.2

14.3 to 14.5

15.6

7.7 to 8.4

13.3

14.6 to 14.7

15.7

8.5 to 8.10

13.4

14.8 to 14.9

15.8

8.11 to 9.3

13.5

14.10 to 15.0

15.9

9.4 to 9.8

13.6

15.1 to 15.2

16.0

9.9 to 10.0

13.7

15.3 to 15.5

16.1

10.1 to 10.4

13.8

15.6 to 15.7

16.2

10.5 to 10.7

13.9

15.8 to 15.10

16.3

10.8 to 10.10

14.0

15.11 to 16.0

16.4

10.11 to 11.2

14.1

16.1 to 16.3

16.5

11.3 to 11.5

14.2

16.4 to 16.6

16.6

11.6 to 11.7

14.3

16.7 to 16.9

16.7

11.8 to 11.10

14.4

16.10 to 17.0

16.8

11.11 to 12.1

14.5

17.1 to 17.3

16.9

12.2 to 12.4

14.6

17.4 to 17.7

17.0

17.8 to 17.11

17.1