Addendum - 0500

Addendum to the Supporting Statement for Forms SSA-4814-F5 and SSA-4815-F6

Medical Report on Adult with Allegation of Human

Immunodeficiency Virus Infection;

Medical Report on Child with Allegation of Human

Immunodeficiency Virus Infection

20 CFR 416.933-416.934

OMB No. 0960-0500

Revision to the Collection Instrument

• Change #1: Addition of a line under the heading “MEDICAL RELEASE INFORMATION” on the SSA-4814-F5

Justification #1: This will provide emphasis to this portion of the SSA-4814-F5.

• Change #2: Change heading of section C. on page 1 of the SSA-4814-F5

From:

“OPPORTUNISTIC AND INDICATOR DISEASES”

To:

“CONDITIONS RELATED TO HIV INFECTION”

Justification #2: This section of the SSA-4814-F5 requests information which we require to make a presumptive disability (PD) determination. This information is criteria related to HIV infection in our Listing of Impairments (listings) that we use to adjudicate disability cases; we are in the process of updating these listings. While many of the current listings are on opportunistic and indicator diseases, our updated listings are on conditions related to HIV infection.

• Change #3: Addition of statement under heading of section C, on page 1 of the SSA‑4814-F5, stating:

“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.”

Justification #3: A review of some cases with PD payments based on the SSA‑4814‑F5 demonstrated to the Social Security Administration (SSA) that medical sources were providing us with information we could not verify through available medical evidence during adjudication of the case. SSA believes we need to remind our medical sources that the medical record must substantiate the information they provide on this form.

• Change #4: Removal of all items (items 1-41) and subheadings in section C of the SSA-4814-F5.

Justification #4: The information SSA requests in this section of the SSA‑4814‑F5 is on the criteria in our listing related to HIV infection. SSA is currently in the late stages of updating these criteria; once the new criteria are effective, all of the criteria that informed the current items in section C will be obsolete.

• Change #5: Addition of items 1-8 in section C of the SSA-4814-F5

Justification #5: The information SSA requests in this section of the SSA‑4814‑F5 is on the criteria in our listing related to HIV infection. SSA is currently in the late stages of updating these criteria; once the new criteria are effective, the information we request in section C must reflect them.

• Change #6: Removal of the instruction box immediately after section C of the SSA‑4814-F5, reading:

“NOTE: If you have checked any of the boxes in section C, 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.

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, precede to sections F and G and sign and date the form.”

Justification #6: Item 6 contains instructions on how to complete current section D of the SSA-4814-F5. Since we will remove all of current section D from the updated SSA-4814-F5 (see change #7 below), there is no need to provide instructions as to how to complete it.

• Change #7: Removal of section D of the SSA-4814-F5

Justification #7: Section D of the SSA-4814-F5 asks the medical source to provide us with information about any repeated manifestations of HIV infection the claimant might have. While this section reflects a specific set of listing criteria, SSA’s experience shows that the information we collect in this section is not helpful in allowing us to ascertain whether there is a high probability that we will approve claimant’s application for disability benefits. Therefore, we will remove it.

• Change #8: Reletter current section E of the SSA-4814-F5 as section D.

Justification #8: Due to the removal of the current section D of the SSA-4814-F5, it is necessary for SSA to redesignate current section E as section D.

• Change #9: In new section D (current section E) of the SSA-4814-F5, change the instruction sentence

From:

“Please use this space if you lack sufficient room in section D or to provide any other comments you wish about your patient.”

To:

“Please use this space to provide any other comments you wish about your patient.”

Justification #9: Due to the removal of the current section D of the SSA-4814-F5, it is no longer necessary to refer to section D in these instructions.

• Change #10: Reletter current section F of the SSA-4814-F5 as section E.

Justification #10: Due to the removal of the current section D of the SSA-4814-F5, it is necessary for SSA to redesignate current section F as section E.

• Change #11: Reletter current section G of the SSA-4814-F5 as section F.

Justification 11: Due to the removal of the current section D of the SSA-4814-F5, it is necessary for SSA to redesignate current section G as section F.

• Change #12: On the instruction sheet of the SSA-4814-F5, change the Roman numerals of list items to Arabic numerals.

Justification #12: We believe this change will make the instruction sheet easier to follow. This change will also provide consistency between the SSA-4814-F5 and the corresponding childhood form, the SSA-4815-F6.

• Change #13: On the instruction sheet of the SSA-4814-F5, under item IV (4), under the fourth bullet, change the second sentence:

From:

“If you check at least one of the items in section C, go right to section E.”

To:

“If you check at least one of the items in section C, go to section D.”

Justification #13: As we are redesignating current section E to section D in the revised SSA-4814-F5, we need to update the instructions to reflect this.

• Change #14: On the instruction sheet of the SSA-4814-F5, under item IV (4), remove the fifth bullet that reads:

“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.”

Justification #14: As we are removing current section D from the SSA-4814-F5 entirely, we no longer need to provide instructions as to how to complete it.

• Change #15: On the instruction sheet of the SSA-4814-F5, under item IV (4), change the sixth bullet:

FROM:

“COMPLETE SECTION E IF YOU WISH TO PROVIDE COMMENTS ON YOUR PATIENT’S CONDITION(S)”

TO:

“COMPLETE SECTION D IF YOU WISH TO PROVIDE COMMENTS ON YOUR PATIENT’S CONDITION(S)”

Justification #15: As we are redesignating current section E to section D in the revised SSA-4814-F5, we need to update the instructions to reflect this.

• Change #16: On the instruction sheet of the SSA-4814-F5, under item 4, change the seventh bullet:

FROM:

“ALWAYS COMPLETE SECTIONS F AND G.”

TO:

“ALWAYS COMPLETE SECTIONS E AND F.”

Justification #16: As we are redesignating current section F to revised section E, and current section G to revised section F in the SSA-4814-F5, we need to update the instructions to reflect this.

• Change #17: On the instruction sheet of the SSA-4814-F5, under the new sixth bullet (current seventh bullet) remove the hard return between “ALWAYS COMPLETE SECTIONS E AND F” and “NOTE: This form is not complete until it is signed.”

Justification #17: This will provide consistency between the SSA-4814-F5 and SSA‑4815-F6.

• Change #18: On the instruction sheet of the SSA-4814-F5, under the new sixth bullet (current seventh bullet) change “This form is not complete until it is signed.” from bold to regular text.

Justification #18: This will provide consistency between the SSA-4814-F5 and SSA‑4815-F6.

• Change #19: On the instruction sheet of the SSA-4814-F5, remove item VI (6).

Justification #19: Item 6 contains instructions on how to complete current section D of the SSA-4814-F5. Since we are removing all of current section D from the updated form, there is no need to provide instructions as to how to complete it.

• Change #20: Addition of a line under the heading “MEDICAL RELEASE INFORMATION” on the SSA-4815-F6

Justification #20: This will provide emphasis to this portion of the SSA-4815-F6.

• Change #21: Change heading of section C. on page 1 of the SSA-4815-F6

From:

“OPPORTUNISTIC AND INDICATOR DISEASES”

To:

“CONDITIONS RELATED TO HIV INFECTION”

Justification #21: This section of the SSA-4815-F6 requests information we require to make a presumptive disability (PD) determination. This information is on criteria related to HIV infection in our Listing of Impairments (listings) that we use to adjudicate disability cases; we are in the process of updating these listings. While many of the current listings are on opportunistic and indicator diseases, our updated listings are on conditions related to HIV infection.

• Change #22: Addition of statement under heading of section C on page 1 of the SSA-4815-F6, stating:

“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.”

Justification #22: A review of some cases with PD payments based on the SSA‑4814-F5, the corresponding form for adults, demonstrated to the SSA that medical sources were providing us with information we could not verify through available medical evidence during adjudication of the case. SSA believes we need to remind our medical sources that the medical record must substantiate the information they provide on Form SSA-4815-F6.

• Change #23: Removal of all items (items 1-47) and subheadings in section C of the SSA-4815-F6.

Justification #23: The information SSA requests in this section of the SSA-4815-F6 is based on the criteria in our listings related to HIV infection. SSA is currently in the late stages of updating these criteria; once the new criteria are effective, all of the criteria that informed the current items in section C will be obsolete.

• Change #24: Addition of items 1-9 in section C of the SSA-4815-F6

Justification #24: The information SSA requests in this section of the SSA-4815-F6 is based on the criteria in our listings related to HIV infection. SSA is currently in the late stages of updating these criteria; once the new criteria are effective, the information we request in section C must reflect them.

• Change #25: Removal of the instruction box immediately after section C of the SSA-4815-F6, reading:

“NOTE: If you have checked any of the boxes in section C, proceed to section E if you have any remarks you wish to make about this patient’s condition. Then, precede 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, precede to sections F and G and sign and date the form.”

Justification #25: We will remove section D of the SSA-4815-F6; therefore, we no longer need these instructions.

• Change #26: Removal of section D of the SSA-4815-F6

Justification #26: Section D asks the medical source to provide us with information about any repeated manifestations of HIV infection the claimant might have and assessment of functional limitations associated with the manifestations. While this section reflects a specific set of current listing criteria, these criteria will not appear in the updated listing. Therefore, we will remove this section entirely.

• Change #27: In new section D (current section E) of the SSA-4815-F6, change the instruction sentence

From:

“Please use this space if you lack sufficient room in section D or to provide any other comments you wish about your patient.”

To:

“Please use this space to provide any other comments you wish about your patient.”

Justification #27: Due to the removal of the current section D of the SSA-4815-F6, it is no longer necessary to refer to section D in these instructions.

• Change #28: Reletter section E as section D of the SSA-4815-F6.

Justification #28: Due to the removal of the current section D of the SSA-4815-F6, it is necessary for SSA to redesignate current section E as section D.

• Change #29: Reletter section F as section E of the SSA-4815-F6.

Justification #29: Due to the removal of the current section D of the SSA-4815-F6, it is necessary for SSA to redesignate current section F as section E.

• Change #30: Reletter section G as section F of the SSA-4815-F6.

Justification #30: Due to the removal of the current section D of the SSA-4815-F6, it is necessary for SSA to redesignate current section G as section F.

• Change #31: On the instruction sheet of the SSA-4815-F6, under item 4, under the fourth bullet, change the second sentence:

From:

“If you check at least one of the items in section C, go right to section E.”

To:

“If you check at least one of the items in section C, go to section D.”

Justification #31: As we are redesignating current section E to section D in the revised SSA-4815-F6, we need to update the instructions to reflect this.

• Change #32: On the instruction sheet of the SSA-4815-F6, under item 4, remove the fifth bullet that reads:

“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.”

Justification #32: As we are removing current section D from the SSA-4815-F6 entirely, we no longer need to provide instructions as to how to complete it.

• Change #33: On the instruction sheet of the SSA-4815-F6, under item 4, change the sixth bullet:

FROM:

“COMPLETE SECTION E IF YOU WISH TO PROVIDE COMMENTS ON YOUR PATIENT’S CONDITION(S)”

TO:

“COMPLETE SECTION D IF YOU WISH TO PROVIDE COMMENTS ON YOUR PATIENT’S CONDITION(S)”

Justification #33: As we are redesignating current section E to section D in the revised SSA-4815-F6, we need to update the instructions to reflect this.

• Change #34: On the instruction sheet, under item 4 of the SSA-4815-F6, change the first sentence under the seventh bullet:

FROM:

“ALWAYS COMPLETE SECTIONS F AND G.”

TO:

“ALWAYS COMPLETE SECTIONS E AND F.”

Justification #34: As we are redesignating current section F to revised section E, and current section G to revised section F in the SSA-4815-F6, we need to update the instructions to reflect this.

• Change #35: On the instruction sheet of the SSA-4815-F6, remove item 6.

Justification #35: Item 6 contains instructions on how to complete current section D of the SSA-4815-F6. Since we are removing all of current section D from the updated form, there is no need to provide instructions as to how to complete it.

• Change #36: Add Table I to SSA-4815-F6, entitled “Males Birth to Attainment of Age 2 – Third Percentile Values for Weight-for-Length”

Justification #36: This table provides values the individuals completing the SSA‑4815-F6 may need to reference if they answer item 9b.

• Change #37: Add Table II to SSA-4815-F6, entitled “Females Birth to Attainment of Age 2 – Third Percentile Values for Weight-for-Length”

Justification #37: This table provides values the individuals completing the SSA‑4815-F6 may need to reference if they answer item 9b.

• Change #38: Add Table III to SSA-4815-F6, entitled “Males Age 2 to Attainment of Age 18 – Third Percentile Values for BMI-for-Age”

Justification #38: This table provides values the individuals completing the SSA‑4815-F6 may need to reference if they answer item 9b.

• Change #39: Add Table IV to SSA-4815-F6, entitled “Females Age 2 to Attainment of Age 18 – Third Percentile Values for BMI-for-Age”

Justification #39: This table provides values the individuals completing the SSA‑4815-F6 may need to reference if they answer item 9b.

• Change #40: SSA intends to provide Forms SSA-4814-F5 and SSA-4815-F6 in fillable PDF files on our website, in place of the non-fillable PDF versions we currently provide. We propose to make all form entries fillable.

Justification #40: This change will allow the respondents to continue to print and complete the forms by hand, or, alternatively, complete the forms using a computing device, such as a personal computer or handheld (mobile) device, print, and submit the forms to SSA for processing.

• Change #41: We are revising the Privacy Act Statement on this form.

Justification #41: SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the form.

On the effective date of the revised medical listings, we will discontinue the current forms; instruct our field offices to begin using the updated instruments; and request destruction of obsolete versions of the form. We will make the forms available to our field offices in hardcopy as well as electronically for local printout. These forms request information which SSA requires to reasonably assume a given claim with allegations of HIV infection has a high probability of approval. We base this assumption largely on a claimant’s medical source providing us with information indicating it is likely that the claimant’s impairment will meet one of our medical listings related to HIV infection. Since we are changing the criteria in these listings, we need to change the information we request on these forms.