How to Fill Out and Submit Form SSA-4814: HIV Infection Medical Report

SSA Form 4814, the Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection, is completed by a medical provider to document an adult SSI claimant’s HIV diagnosis and qualifying complications, then submitted to the claimant’s local Social Security field office so presumptive SSI payments of up to $994 per month can begin while the full disability claim is reviewed.¹ A separate form, SSA-4815-F6, handles the same process for children.²

The form exists to give the field office enough documented medical evidence to make a presumptive disability finding on the spot under 20 CFR 416.933, rather than waiting months for Disability Determination Services to finish a full review.³ Presumptive payments run up to six months and end when SSA issues its formal decision, the sixth payment goes out, or the claimant no longer meets a non-medical eligibility rule, whichever comes first.⁴ In most states, SSI eligibility also opens automatic Medicaid coverage during that window.⁵

Who Completes the Form

The claimant does not fill out Form 4814. A physician, nurse, or other hospital or clinic staff member who can confirm the diagnosis and severity completes and signs it.¹ The form can also be completed by phone: the field office worker fills it in during a call with the medical source and notes in the signature block that it was completed “per telephone conversation,” along with the source’s name, title, and date.²

When the field office mails the form to the medical source, it includes Form SSA-827 (Authorization to Disclose Information to the Social Security Administration) so the provider has proper authorization to release the claimant’s records.²

Filling Out Each Section

The form has six sections, A through F. Every required section must be complete. If any is missing or wrong, the field office will note that a presumptive determination could not be made, and the claimant loses weeks of potential payments.²

Section A: Identifying Information

Section A collects the claimant’s name, Social Security number, phone number, address, date of birth, and the name of the medical source. When the field office mails the form out, it pre-fills this section along with its three-digit field office code.¹

Section B: How HIV Was Diagnosed

Section B has two checkboxes. The medical source checks one or both to indicate whether the diagnosis rests on laboratory testing that confirmed the infection, on other clinical and laboratory findings combined with medical history, or on both. At least one box must be checked.¹

Section C: Conditions Related to HIV Infection

Section C is the core of the form and where most incomplete submissions stall. It lists eight numbered categories mirroring the adult HIV disability listing (Listing 14.11) in SSA’s Blue Book.⁶ The medical source checks every category that applies and fills in specific measurements where the form requires them. At least one item must be completed.²

The eight categories:

Item 1, multicentric Castleman disease affecting multiple groups of lymph nodes or organs containing lymphoid tissue. Localized or unicentric Castleman disease does not qualify.
Item 2, primary central nervous system lymphoma.
Item 3, primary effusion lymphoma.
Item 4, progressive multifocal leukoencephalopathy.
Item 5, pulmonary Kaposi sarcoma.
Item 6, CD4 count of 50 cells/mm³ or less. The medical source must record the exact measurement, the date it was recorded, and the ordering provider.
Item 7, CD4 count of 200 cells/mm³ or less (or CD4 percentage below 14 percent) combined with either a BMI below 18.5 or hemoglobin below 8.0 g/dL. Both parts (a and b) must be completed. The CD4 measurement and the BMI or hemoglobin measurement don’t have to come from the same date, but each one needs its value, date, and ordering provider.
Item 8, HIV complications requiring three or more hospitalizations in a 12-month period. Each hospitalization must last at least 48 hours (including emergency department time immediately before admission) and must be at least 30 days apart from the others.

These categories are drawn directly from the form.¹ On items 6 and 7, the most common reason a form gets held up is a missing date or a missing ordering provider name. Pull these from lab reports rather than working from memory.

Section D: Remarks

Section D is free text. Use it for clinical details that support the claim but don’t fit Section C’s checkboxes, including symptoms, treatment history, or other conditions. The full DDS review can consider recurring HIV manifestations that individually fall short of the eight criteria but together cause marked limitations in daily activities, social functioning, or the ability to complete tasks on time, so anything relevant belongs here.⁶

Sections E and F: Medical Source and Signature

Section E requires the medical source’s full name, office address, and telephone number with area code. Section F requires the signature, professional title (for example, “physician” or “R.N.”), and the date. Both must be complete. A missing signature or title alone is enough for the field office to decline a presumptive finding.²

What the Field Office Checks

Before authorizing presumptive payments, field office staff verify four things: Section B has at least one box checked, Section C has at least one numbered item completed, Section E is filled in, and Section F has a signature with a professional title. If all four are present and the claimant meets non-medical SSI requirements, the office enters the presumptive disability finding and issues payment.² Disability Determination Services isn’t limited to the categories on the form and can also make a presumptive finding later, based on other evidence.⁷

Form 4814 covers only the medical side. The field office separately verifies SSI’s income and resource limits before releasing payment.

Where to Submit It

Form 4814 goes to the claimant’s local SSA field office. You can send it by fax, by mail, or through the office drop box.⁸ The nearest office and its fax number are listed through SSA’s office locator at secure.ssa.gov/ICON/main.jsp. Keep a copy before sending. The presumptive payment clock starts once the field office reviews the medical evidence, so any delay in delivery becomes a delay in benefits.

If the medical source completes the form by phone with the field office, no separate submission is needed. The office creates the record during the call.²

After Payments Begin

Once the field office authorizes presumptive disability, payments of up to $994 per month (the 2026 federal SSI rate for an individual) begin in the next payment cycle, assuming income and resource limits are met.⁹ While payments run, the claim moves to state DDS for full review, and DDS may request additional hospital records, lab results, or specialist evaluations. If the final decision is favorable, presumptive payments transition into regular SSI without a gap.

During this period, report any change in income, resources, living arrangements, or address to SSA no later than 10 days after the end of the month in which the change occurred. Failure to report can bring penalties of $25 to $100 per unreported change. Knowingly false statements can trigger payment suspensions of 6 months for a first offense, 12 months for a second, and 24 months after that.¹⁰

If the Final Decision Is a Denial

If SSA ultimately decides the claimant does not meet the full disability standard, the presumptive payments already received do not have to be repaid. SSA treats them as non-recoverable. The only exception is an overpayment that arose for a separate reason, such as income or resources exceeding SSI limits during the payment period.¹¹

If SSA identifies an overpayment tied to non-medical factors, the claimant can request a waiver by filing Form SSA-632. The waiver requires showing that the overpayment was not the claimant’s fault and that repayment would be unaffordable. SSA pauses recovery efforts while the waiver request is under review.¹²

1
Social Security Administration. SSA Form 4814 – Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
2
Social Security Administration. DI 11055.241 – Presumptive Disability and Presumptive Blindness – HIV/AIDS Cases
3
Social Security Administration. 20 CFR 416.933 – How We Make a Finding of Presumptive Disability or Presumptive Blindness
4
eCFR. 20 CFR 416.932 – Presumptive Disability and Presumptive Blindness
5
Social Security Administration. State Medicaid Eligibility and Enrollment Policies and Rates
6
Social Security Administration. 14.00 Immune System Disorders – Adult
7
Social Security Administration. DI 23535.012 – DDS Responsibilities in Presumptive Disability Cases Involving HIV/AIDS
8
Social Security Administration. Submit Forms and Upload Documents
9
Social Security Administration. SSI Federal Payment Amounts for 2026
10
Social Security Administration. Understanding Supplemental Security Income Reporting Responsibilities
11
Social Security Administration. Expedited Payments – Supplemental Security Income
12
Social Security Administration. Request for Waiver of Overpayment Recovery or Change in Repayment Rate