Form Dhcs 7035 C - California Medical Report On Child With Allegation Of Human Immunodeficiency Virus Infection - Health And Welfare Agency

State of California—Health and Welfare Agency

Department of Health Care Services

MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED DHCS 7035 C

(Medical Report on Child With Allegation of Human Immunodeficiency Virus [HIV] Infection)

A claim has been filed for your patient, identified in Section A of the attached form, 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’s parent or guardian 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’s parent or guardian.

IV. HOW TO COMPLETE THE FORM:

If you receive the form from your patient’s parent or guardian 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’s parent or guardian 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. Complete only the areas of functioning applicable to the child’s age group.

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 the extent described.

For children age 3 to attainment of age 18, the child must have a “marked” restriction of functioning in two areas to be eligible for these benefits. See

below for an explanation of the term “marked.”

Special Terms Used in Section D:

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., oral candidiasis not

meeting the criteria shown in Item 27 of the form, diarrhea not meeting the criteria shown in Item 38 of the form); or any other conditions that is not listed

in Section C, (e.g., oral hairy leukoplakia, hepatomegaly).

Continued on reverse

DHCS 7035 C (Coversheet) (04/08)