Form SSA-4815 "Petition for Authorization to Charge and Collect a Fee for Services Before the Social Security Administration"

What Is Form SSA-4815?

This is a legal form that was released by the U.S. Social Security Administration on January 1, 2020 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest available edition released by the U.S. Social Security Administration;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SSA-4815 by clicking the link below or browse more documents and templates provided by the U.S. Social Security Administration.

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Form SSA-4815 (01-2020) UF
Discontinue Prior Editions
Page 1 of 9
Social Security Administration
OMB NO. 0960-0500
FO CODE:
MEDICAL REPORT ON CHILD 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 the child's treatment for human immunodeficiency virus
(HIV) infection.
CLAIMANT'S PARENT'S OR GUARDIAN'S SIGNATURE (Required only if Form SSA-827 is NOT attached) DATE
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,
Laboratory testing confirming HIV infection
and diagnosis(es) indicated in the medical evidence
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
6. CD4 Count: Please indicate measurement, date recorded,
disease
AND ordering provider
Affecting multiple groups of lymph nodes
Affecting organs containing lymphoid tissue
a. Birth to attainment of age 1:
2.
Primary central nervous system lymphoma
3
Absolute CD4 count of 500 cells/mm
or less
3.
Primary effusion lymphoma
CD4 percentage of less than 15 percent
4.
Progressive multifocal leukoencephalopathy
b. Age 1 to attainment of age 5:
3
Absolute CD4 count of 200 cells/mm
or less
5.
Pulmonary Kaposi sarcoma
CD4 percentage of less than 15 percent
c. Age 5 to attainment of age 18:
3
Absolute CD4 count of 50 cells/mm
or less
Form SSA-4815 (01-2020) UF
Discontinue Prior Editions
Page 1 of 9
Social Security Administration
OMB NO. 0960-0500
FO CODE:
MEDICAL REPORT ON CHILD 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 the child's treatment for human immunodeficiency virus
(HIV) infection.
CLAIMANT'S PARENT'S OR GUARDIAN'S SIGNATURE (Required only if Form SSA-827 is NOT attached) DATE
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,
Laboratory testing confirming HIV infection
and diagnosis(es) indicated in the medical evidence
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
6. CD4 Count: Please indicate measurement, date recorded,
disease
AND ordering provider
Affecting multiple groups of lymph nodes
Affecting organs containing lymphoid tissue
a. Birth to attainment of age 1:
2.
Primary central nervous system lymphoma
3
Absolute CD4 count of 500 cells/mm
or less
3.
Primary effusion lymphoma
CD4 percentage of less than 15 percent
4.
Progressive multifocal leukoencephalopathy
b. Age 1 to attainment of age 5:
3
Absolute CD4 count of 200 cells/mm
or less
5.
Pulmonary Kaposi sarcoma
CD4 percentage of less than 15 percent
c. Age 5 to attainment of age 18:
3
Absolute CD4 count of 50 cells/mm
or less
Form SSA-4815 (01-2020) UF
Page 2 of 9
7. 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.
Date of
Complication of HIV Infection
Duration
Name of Hospital
Hospitalization
Example:
Example: Diarrhea
Example: 2 days
Example: Memorial Hospital
December 2, 2015
8. Neurological manifestation of HIV infection including, but not limited to, HIV encephalopathy or peripheral neuropathy,
resulting in one of the following specified impairments. Either both a and b or a and c are required.
a. Neurological manifestation (please specify):
Resulting in b. or c.
b. Each of these items requires two examinations at least 60 days apart. You must check the appropriate impairment and
fill out the table indicating the dates of examination
Loss of previously acquired developmental milestones or intellectual ability (including the sudden onset of a new
learning disability), documented on two examinations at least 60 days apart
Progressive motor dysfunction affecting gait and station or fine and gross motor skills, documented on two
examinations at least 60 days apart
Microcephaly with head circumference that is less than the third percentile for age, documented on two
examinations at least 60 days apart
PROVIDER (if other than the person
DATE OF EXAMINATION
DETAILS (if applicable)
completing form)
OR
c.
Brain atrophy, documented by appropriate medically acceptable imaging
DATE OF IMAGING
DETAILS (if applicable)
IMAGING CENTER
9. Immune suppression and growth failure. Both a and b are required.
a. CD4 count:
From birth to attainment of age 5, CD4 percentage of less than 20 percent
Please indicate measurement, date recorded, AND ordering provider
3
From age 5 to attainment of age 18, absolute CD4 count of less than 200 cells/mm
or CD4 percentage of less than 14
percent. Please indicate measurement, date recorded, AND ordering provider
Form SSA-4815 (01-2020) UF
Page 3 of 9
b. Growth failure:
For children from birth to attainment of age 2, three weight-for-length measurements that are:
• Within a consecutive 12-month period; and
• At least 60 days apart; and
• Less than the third percentile on the appropriate weight-for-length table on pages 6-7.
DATE
LENGTH (cm)
WEIGHT (kg)
For children age 2 to attainment of age 18, three BMI-for-age measurements that are:
• Within a consecutive 12-month period; and
• At least 60 days apart; and
• Less than the third percentile on the appropriate BMI-for-age table on pages 8-9.
DATE
AGE (years and months)
BMI
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
FIELD OFFICE DISPOSITION:
FOR
OFFICIAL
USE
DISABILITY DETERMINATION SERVICES DISPOSITION:
ONLY
Form SSA-4815 (01-2020) UF
Page 4 of 9
MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED SSA-4815
(Medical Report On Child With Allegation Of Human Immunodeficiency Virus (HIV) Infection)
A claim has been filed for your patient, identified in section A of the attached form, 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's parent or guardian 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's
parent or guardian.
4. HOW TO COMPLETE THE FORM:
• If you receive the form from your patient's parent or guardian 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's parent or guardian for return to the SSA field office.
Form SSA-4815 (01-2020) UF
Page 5 of 9
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/.
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.
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