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

SSA uses Forms SSA-4814 and SSA-4815 to collect the information necessary to determine if an individual with human immunodeficiency virus (HIV) infection, who is applying for SSI disability payments, meets the requirements for PD. SSA mails the appropriate paper form to the claimant's medical source to complete and return to SSA. Respondents can complete this collection via the paper forms or telephone interview. When respondents complete these forms via telephone interview, which per our Management Information data, is most often, FO or DDS personnel enter the information from the respondents directly into the form, and document the medical source’s name, title, and date in the signature block. We then fax the form into the electronic case file. If SSA FO staff is unable to make a PD finding based on the information the applicant’s medical source provides, the DDS agency makes a determination at their discretion. The respondents are the medical sources of the applicants for SSI disability payments. We are updating all the fields where we request date on Form SSA-4814 and SSA-4815. We are adding an arrow on the side where the respondent can pull up a calendar and select the date (the respondent can still type in the date in any format they choose). We are also revising the date format from December 2, 2015 to 12/2/2015.

The latest form for Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child expires 2026-04-30 and can be found here.

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

Federal Enterprise Architecture: Income Security - General Retirement and Disability

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