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

SSA will insert the following Privacy Act & PRA Statements 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 you provide 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 (e.g., employers and private pension plans) in situations where the
party to be contacted has, or is expected to have, information relating to the individual’s
capability to manage his or her benefits or payments, or his or her eligibility for or
entitlements to benefits or eligibility for payments, 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. We
disclose information under this routine use only in situations in which we may enter into
a contractual or similar agreement with a third party to assist in accomplishing an agency
function relating to this system of records.

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 Notices
(SORNs) 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 600320, entitled Electronic Disability (eDIB) Claim File, as published in the FR on June 4, 2020, at
85 FR 34477. Additional information, and a full listing of all our SORNs, is available on our
website at www.ssa.gov/privacy.

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. We estimate that it will take about 10 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.