Form Dhcs 7035 A - California Medical Report On Adult With Allegation Of Human Immunodeficiency Virus Infection - Health And Human Services Agency Page 2
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Manifestations of HIV must result in significant, documented symptoms and signs, (e.g., fatigue, fever, malaise, weight loss, pain,
night sweats).
What We Mean By “Marked” Limitation or Restriction in Functioning (see Item D.2):
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When “marked” is used to describe functional limitations, it means more than moderate, but less than extreme. “Marked” does not
imply that your patient is confined to bed, hospitalized, or in a nursing home.
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A marked limitation may be present when several activities or functions are impaired or even when only one is impaired. An
individual need not be totally precluded from performing an activity to have a marked limitation, as long as the degree of limitation is
such as to seriously interfere with the ability to function independently, appropriately, and effectively.
What We Mean By “Activities of Daily Living” (see Item D.2):
●
Activities of daily living include, but are not limited to, such activities as doing household chores, grooming and hygiene, using a post
office, taking public transportation, and paying bills.
Example: An individual with HIV infection who, because of symptoms such as pain imposed by the illness or its treatment, is not
able to maintain a household or take public transportation on a sustained basis or without assistance (even though he or she is able
to perform some self-care activities) would have marked limitation of activities of daily living.
What We Mean By “Social Functioning” (see Item D.2):
●
Social functioning includes the capacity to interact appropriately and communicate effectively with others.
Example: An individual with HIV infection who, because of symptoms or a pattern of exacerbation and remission caused by the
illness or its treatment, cannot engage in social interaction on a sustained basis (even though he or she is able to communicate with
close friends or relatives) would have marked difficulty in maintaining social functioning.
What We Mean By “Completing Tasks in a Timely Manner” (see Item D.2):
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Completing tasks in a timely manner involves the ability to sustain concentration, persistence, or pace to permit timely completion of
tasks commonly found in work settings.
Example: An individual with HIV infection who, because of HIV-related fatigue or other symptoms, is unable to sustain
concentration or pace adequate to complete simple work-related tasks (even though he or she is able to do routine activities of daily
living) would have marked difficulty completing tasks.
PRIVACY ACT NOTICE
The California Department of Health Care Services (DHCS) is authorized to collect the information on this
form under Sections 205(a), 233(d), and 1633(e)(1) of the Social Security Act. The information on this form
is needed by DHCS to make a decision on the named applicant’s application for Medi-Cal based on
disability. While giving us the information on this form is voluntary, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named applicant’s application.
Although the information you furnish is almost never used for any
purpose other than making a
determination about the applicant’s disability, such information may be disclosed by DHCS as follows:
(1) to enable a third party or agency to assist DHCS in establishing rights to Medi-Cal benefits, and (2)
to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the
Medi-Cal program.
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other federal, state, and local government agencies. Many agencies may
use matching programs to find or prove that a person qualifies for benefits paid by the Federal Government.
The law allows us to do this even if you do not agree to it.
Federal law governing Medicaid requires that medical information on applicants and beneficiaries be kept
confidential. [(42 United States Code, Section 139a (a) (7).)] The regulations implementing this law deal with
the disclosure of information collected and maintained by state Medicaid agencies. (42 California Federal
Register, Sections 431.300 et seq.)
Page 2 of 2
DHCS 7035 A (06/07)
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