Form SSA-4814 Medical Report on Adult with Allegation of Human Immunod

Form SSA-4814 (01-2020) UF
Discontinue Prior Editions
Social Security Administration

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OMB NO. 0960-0500
FO CODE:

MEDICAL REPORT ON ADULT 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 my treatment for human immunodeficiency virus (HIV)
infection.
DATE
CLAIMANT'S SIGNATURE (Required only if Form SSA-827 is NOT attached)

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?
Other clinical and laboratory findings, medical
history, and diagnosis(es) indicated in the
medical evidence

Laboratory testing confirming HIV infection

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
Affecting organs containing lymphoid tissue
2.

Primary central nervous system lymphoma

3.

Primary effusion lymphoma

4.

Progressive multifocal leukoencephalopathy

5.

Pulmonary Kaposi sarcoma

6. CD4 Count: Absolute CD4 count of 50 cells/mm3 or less
Please indicate measurement, date recorded, AND
ordering provider

7. CD4 level and BMI or hemoglobin measurements
(values do not have to be measured on the same date),
with a and b.
a. CD4 level
Absolute CD4 count of 200 cells/mm3 or less
OR
CD4 percentage of less than 14 percent
Please indicate measurement, date recorded, AND
ordering provider

AND
b. BMI or hemoglobin
BMI measurement of less than 18.5
OR
Hemoglobin measurement of less than 8.0 grams
per deciliter
Please indicate measurement, date recorded, AND
ordering provider

Form SSA-4814 (01-2020) UF

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8. 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

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-4814 (01-2020) UF

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MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED SSA-4814
(Medical Report On Adult With Allegation Of Human Immunodeficiency Virus (HIV) Infection)
Your patient, identified in section A of the attached form, has filed a claim 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 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.

4. HOW TO COMPLETE THE FORM:
• If you receive the form from your patient 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 for return to the SSA field office.

Form SSA-4814 (01-2020) UF

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Privacy Act Statement
See Revised Privacy Act &
Collection and Use of Personal Information PRA Statements attached.
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/.

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 8 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.