Form SSA 4814-F5, Medical Report on Adult with Allegation of HIV Infection (2004)

Client/Agency Forms

This essential form, unavailable on the Social Security Administration's website, is used by a disability applicant's health care provider to establish to the SSA field office processing the claim that manifestations of the applicant's HIV disease are sufficiently severe to warrant presumptive eligibility for benefits. According to SSA, this form was created to provide information to the SSA field office in order to permit the earliest possible payments to people living with HIV infection. The field office may make a finding of presumptive disability for any individual with HIV infection whose doctor provides information that confirms that the individual's disease manifestations are of listing-level severity, regardless of whether the individual has been diagnosed with AIDS. The relevant federal code provision is located at 20 C.F.R. § 416.933.

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