Form Dhcs 7035 A - California Medical Report On Adult With Allegation Of Human Immunodeficiency Virus Infection - Health And Human Services Agency

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State of California—Health and Human Services Agency
Department of Health Care Services
MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED DHCS 7035 A
(Medical Report on Adult With Allegation of Human Immunodeficiency Virus [HIV] Infection)
Your patient, identified in Section A of the attached form, has filed a claim for Medi-Cal disability benefits based on HIV infection.
MEDICAL SOURCE: Please detach this instruction sheet and use it to complete the attached form.
I. PURPOSE OF THIS FORM:
If you complete and return the attached form promptly, your patient may be able to receive medical benefits while we are
processing his or her claim for ongoing disability benefits.
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 Evaluation Division may contact you later to obtain further evidence needed to process your patient’s claim.
II. 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.
III. MEDICAL RELEASE:
A Department of Health Care Services medical release (MC 220) signed by your patient 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.
IV. HOW TO COMPLETE THE FORM:
If you receive the form from your patient 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 check at least one of the items in Section C, go right to Section E.
Only complete Section D if you have not checked any item in Section C. See the special information section below which will
help you to complete Section D.
Complete Section E if you wish to provide comments on your patient’s condition(s).
Always complete Sections F and G. Note: This form is not complete until it is signed.
V. 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 without a return envelope, give the completed, signed form back to your patient for return to the county
department of social services.
VI. SPECIAL INFORMATION TO HELP YOU TO COMPLETE SECTION D:
How We Use Section D:
Section D asks you to tell us what other manifestations of HIV your patient may have. It also asks you to give us an idea of how your
patient’s ability to function has been affected.
We do not need detailed descriptions of the functional limitations imposed by the illness; we just need to know whether your
patient’s ability to function has been affected to a “marked” degree in any of the areas listed. See below for an explanation of the
term “marked.”
Special Terms Used in Section D:
What We Mean By “Repeated” Manifestations of HIV Infection (see Item D.1) :
“Repeated” means that a condition or combination of conditions:
Occurs an average of three times a year, or once every four months, each lasting two weeks or more; or
Does not last for two weeks, but occurs substantially more frequently than three times in a year or once every four months; or
Occurs less often than an average of three times a year or once every four months but lasts substantially longer than two weeks.
What We Mean By “Manifestations of HIV Infection (see Item D.1) :
“Manifestations of HIV Infection” may include:
Any conditions listed in Section C, but without the findings specified there, (e.g., carcinoma of the cervix not meeting the criteria
shown in Item 22 of the form, diarrhea not meeting the criteria shown in Item 33 of the form); or any other condition that is not listed
in Section C, (e.g., oral hairy leukoplakia, myositis).
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DHCS 7035 A (06/07)

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