TN 70 (01-17)

DI 11055.241 Field Office (FO) Responsibilities in Presumptive Disability (PD) Claims with an Allegation of Human Immunodeficiency Virus (HIV) Infection or Acquired Immunodeficiency Syndrome (AIDS)

This section provides FO instructions for determining PD claims with an allegation of HIV infection or AIDS. The FO may make a PD determination for a claimant:

  • who alleges HIV infection (regardless of diagnosis of AIDS); and

  • whose medical source provides information that confirms the claimant’s manifestations of HIV infection. (This criteria is included in the check-blocks discussed in DI 11055.241D and DI 11055.241E in this section).

Confirm the presence of the disease manifestations by obtaining one of the following forms from the claimant’s medical source:

  • SSA-4814-F5 (Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection) (OS 15020.510); or

  • SSA-4815-F6 (Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection) (OS 15020.515).

A. Claimant alleges HIV infection or AIDS

If the claimant alleges having HIV or AIDS, follow the instructions in this subsection.

NOTE: If the claim meets the TERI criteria, refer to The Disability Interview – Identifying Terminal Illness (TERI) Cases in DI 11005.601.

1. Claimant has no medical source

a. Electronic cases

Take the following actions:

  • annotate "No Medical Source/CE Needed” in the Remarks section on the SSA-3367 (Disability Report – Field Office);

  • add the AIDS Case (Special-A) flag and include the remark, “No Medical Source/CE Needed;” and

  • transfer the case to the Disability Determination Services (DDS) after you follow current procedures for completing the non-medical development.

b. Paper folders

Take the following actions:

  • flag the folder with Form SSA-408 (Route Slip); and

  • annotate “Expedite – Delayed Case” and include “No Medical Source/CE Needed” to alert the DDS to set up a consultative examination (CE) promptly.

2. Claimant has a medical source

Take the following actions:

  • request the SSA-4814 or SSA-4815 (see DI 11055.241B in this section);

  • document the mainframe (see DI 11055.241B.3. in this section); and

  • transfer the case to the DDS after you follow current procedures for completing the non-medical development.

REMINDER: Do not hold the case while you wait for the SSA-4814 or SSA-4815.

B. Acquiring the completed SSA-4814 or SSA-4815 from the medical source

Even though the SSA-4814 and SSA-4815 contains an abbreviated medical release, also send Form SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)). Use the abbreviated medical release for situations in which the medical source completes the form without access to an SSA-827.

1. Completing the form via telephone

If you contact the medical source directly via the telephone, take the following actions:

  • complete the appropriate blocks of the SSA-4814 or SSA-4815 with the medical source by following the instructions on the form;

  • document in the signature block, “Per telephone conversation with (medical source’s name, title, and date);” and

  • create a barcode and fax the form into the Certified Electronic Folder (CEF) (see DI 81010.090).

NOTE: For paper folders, file the SSA-4814 or SSA-4815 in the Yellow (Back) Medical Records section (see DI 70005.005F).

2. Mailing the form to the medical source for completion

Take the following actions:

  • enter the three-digit FO code in the space marked “FO Code”;

  • check the first block, “Form SSA-827 attached” under the “Medical Release Information” section;

  • complete “Section A;” and

  • mail the form and signed SSA-827 to the medical source for completion. Include a return envelope addressed to the claims specialist (CS) handling the claim to ensure speedy handling.

When the SSA-4814 or SSA-4815 is returned to the FO, refer to DI 11055.241C in this section.

3. Documenting the mainframe

Take the following actions:

  1. Document the date you mailed the form to the medical source on the:

    • development worksheet (DW01) in Modernized Supplemental Security Income Claims System (MSSICS) and, if applicable, on Modernized Claims System (MCS); and

    • remarks section of the SSA-3367 in the Electronic Disability Collect System (EDCS).

  2. Add the Special-A flag for allegations of HIV or AIDS in EDCS. Include the remark, “SSA-4814/SSA-4815 requested on MM/DD/YYYY. Will fax into CEF upon receipt.”

  3. Document the medical source's name, address, telephone number, and fax number as indicated on the SSA-4814 or SSA-4815 in the Remarks section of the DW01 in MCS and MSSICS, as applicable.

NOTE: For paper cases, document the date you mailed the form to the medical source and the medical source’s contact information in “Item 12” on the paper Form SSA-3367. File the SSA-3367 in the Yellow (Back) Medical Records section. See DI 70005.005F.

C. SSA-4814 or SSA-4815 returned to the FO and the claim is pending at the DDS

If the claimant brings the completed form to the FO or the FO receives a faxed form and the case was already been transferred to the DDS, take the following actions:

  • verify the signature. Accept completed forms signed by a medical source (e.g., physician, nurse, or other acceptable member of a hospital or clinic staff), confirming the diagnosis and severity of the HIV disease manifestation. If there is any question about the validity of the signature, verify with the medical source before making a PD finding; and

  • evaluate the form for an adult (DI 11055.241D) or for a child (DI 11055.241E) according to instructions in this section.

If there is any doubt about whether the medical source transmitted the form via fax, call the medical source to:

  • verify that the evidence received via fax was, in fact, transmitted from the medical source; and

  • document the telephone contact on a SSA-5002 (Report of Contact) and fax it into the CEF. Also, document the DW01 in MSSICS and if applicable, MCS.

D. Evaluating the completed Form SSA-4814 (adult)

Use these guidelines when you receive a completed SSA-4814.

Make a PD finding if all of the following are true:

  • Section B – Either block is checked.

  • Section C – One or more numbered item is completed.

  • Section E – The medical source completed this section.

  • Section F – The medical professional signed his or her name and provided his or her title.

E. Evaluating the completed SSA-4815 (child)

Use these guidelines when you receive a completed SSA-4815.

Make a PD determination if all of the following are true:

  • Section B – Either block is checked.

  • Section C – One or more numbered item is completed.

  • Section E – The medical source completed this section.

  • Section F – The medical professional signed his or her name and provided his or her title.

F. Making a PD determination

Make a PD determination after you receive and evaluate a completed SSA-4814 or SSA-4815.

1. FO is able to make a PD finding

Complete the SSA-3367.

a. Electronic cases

The FO must annotate the PD information in MSSICS in order for the PD criterion to propagate into EDCS. If the PD criterion does not propagate, manually annotate “HIV” under the PD section of the electronic SSA-3367 and indicate in Section 11 that the claimant has provided medical evidence.

Take the following actions:

  • check the “FO Disposition” block on the SSA-4814 or SSA-4815;

  • annotate “PD found and input made on MM/DD/YYYY;”

  • issue payment if the claimant meets all non-medical requirements;

  • if an emergency advance payment (EAP) is appropriate, see DI 11055.245;

  • fax the completed SSA-4814 or SSA-4815 into the CEF (DI 81010.090); and

  • destroy the paper form per DI 81020.055E.

b. Paper cases

Take the following actions:

  • complete the following on the paper SSA-3367:

    • Section 8, Item 12, if the claimant meets the PD criteria; and

    • Section 11, if the claimant brought medical evidence into the FO.

  • file the form in the Yellow (Back) Medical Records section. See DI 70005.005F.

    1. Folder is in the FO

      Take the following actions:

      • record the PD determination on the SSA-3367 in EDCS or Form SSA-831 (Disability Determination and Transmittal), as indicated in (DI 11055.240D);

      • attach Form SSA-408 to the folder and annotate “Expedite – SSA-4814/SSA-4815 requested on MM/DD/YYYY,” at the FO’s discretion; and

      • forward the folder to the DDS.

    2. Folder is at the DDS

      If the folder is at the DDS, the FO must send the SSA-4814 or SSA-4815 form to the DDS with an attached SSA-408 for association with the folder, including the remark, “PD finding by FO.”

2. FO is unable to make a PD determination

a. The FO has not sent the claim to the DDS

Take the following actions:

  • check the “FO Disposition” block of the SSA-4814 or SSA-4815;

  • annotate that a PD determination was not made due to inappropriate or incorrect completion;

  • fax the form into the CEF.

    NOTE: If the claim is paper, attach the SSA-408 and file the form in the Yellow (Back) Medical Records section of the paper MDF.

  • send the claim to the DDS.

b. The FO has already sent the claim to the DDS

Take the following actions:

  • check the “FO Disposition” block of the SSA-4814 or SSA-4815;

  • annotate that a PD determination was not made due to inappropriate or incorrect completion; and

  • fax the form into the CEF.

    NOTE: If the claim is paper, attach an SSA-408 and forward the paper SSA-4814 or SSA-4815 for association with the paper MDF.


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DI 11055.241 - Field Office (FO) Responsibilities in Presumptive Disability (PD) Claims with an Allegation of Human Immunodeficiency Virus (HIV) Infection or Acquired Immunodeficiency Synd