Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 1614(a)(3), 1631(a)(4), 1631(e)(1), and 1633 of the Social Security Act, as amended,
allow us to collect this information. We will use the information you provide to make a
determination on the named individual’s disability claim.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely decision on the claim.
We rarely use the information you supply for any purpose other than what we state above,
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 list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices, 60-0103, entitled Supplemental Security Income
Record, and Special Veterans Benefits, and 60-0320, entitled Electronic Disability (eDIB) Claim
File. Additional information about these and other system of records notices and our programs
is available from our Internet website at www.socialsecurity.gov or at your local Social Security
office.
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
incorrect payments or delinquent debts under these programs.