Form Dhcs 7035 C - California Medical Report On Child With Allegation Of Human Immunodeficiency Virus Infection - Health And Welfare Agency Page 3
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6State of California—Health and Welfare Agency
Department of Health Care Services
MEDICAL REPORT ON CHILD WITH ALLEGATION OF
HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION
The individual named below has filed an application for disability under the Medi-Cal program. If you complete this form, your patient
may be able to receive early medical benefits. (This is not a request for an examination, but for existing medical information.)
MEDICAL RELEASE INFORMATION
Form MC 220, “Authorization to Release Medical Information” to the Department of Health Care Services, attached.
I hereby authorize the medical source named below to release or disclose to the Department of Health Care Services or Department of Social Services
any medical records or other information regarding the child’s treatment for human immunodeficiency virus (HIV) infection.
Applicant’s Parent’s or Guardian’s Signature (Required only if Form MC 220 is NOT attached)
Date
A.
IDENTIFYING INFORMATION:
Medical Source’s Name
Applicant’s Name
Applicant’s Social Security Number
Applicant’s Date of Birth
B.
HOW WAS HIV INFECTION DIAGNOSED?
Laboratory testing confirming HIV infection
Other clinical and laboratory findings, medical history, and diagnosis(es)
indicated in the medical evidence
C.
OPPORTUNISTIC AND INDICATOR DISEASES (Please check, if applicable):
B
I
:
ACTERIAL
NFECTIONS
1.
Mycobacterial Infection,
(e.g. caused by M. avium-intracellulare,
M. kansasii, or M. tuberculosis), at a site other than the lungs, skin, or
cervical or hilar lymph nodes
2.
Pulmonary Tuberculosis,
resistant to treatment
3.
Nocardiosis
4.
Salmonella Bacteremia,
recurrent nontyphoid
5.
Syphilis or Neurosyphilis,
(e.g., meningovascular syphilis)
resulting in neurologic or other sequelae
6.
Multiple or Recurrent
In a child less than 13 years of age,
Pyogenic Bacterial Infection(s)
of the following types: sepsis,
pneumonia, meningitis, bone or joint infection, or abscess or an
internal organ or body cavity (excluding otitis media or superficial skin
or mucosal abscesses) occurring two or more times in two years
7.
Multiple or Recurrent Bacterial Infection(s),
including pelvic
inflammatory disease, requiring hospitalization or intravenous antibiotic
treatment three or more times in one year
F
I
:
UNGAL
NFECTIONS
8.
Aspergillosis
9.
Candidiasis,
at a site other than the skin, urinary tract, intestinal
tract, or oral or vulvovaginal mucous membranes; or candidiasis
involving the esophagus, trachea, bronchi, or lungs
DHCS 7035 C (04/08)
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