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

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 1631 and 1633 of the Social Security Act, as amended, allow us to collect this information. 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 will use the information to make a determination on the named individual’s Supplemental Security Income disability claim. We may also share your information for the following purposes, called routine uses:

• To third party contacts in situations where the party to be contacted has, or is expected to have, information relating to the individual’s capability to manage his/her affairs or his/her eligibility for or entitlement to benefits under the Social Security program; and

• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration in the efficient administration of its programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1830; and 60-0320, entitled Electronic Disability (eDIB) Claim File, as published in the FR on December 22, 2005 at 68 FR 71210. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy/.