PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT (PATIENT'S CAPABILITY TO MANAGE BENEFITS)

ICR 198811-0960-004

OMB: 0960-0024

Federal Form Document

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ICR Details
0960-0024 198811-0960-004
Historical Active 198511-0960-004
SSA
PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT (PATIENT'S CAPABILITY TO MANAGE BENEFITS)
Extension without change of a currently approved collection   No
Regular
Approved without change 01/05/1989
Retrieve Notice of Action (NOA) 11/10/1988
  Inventory as of this Action Requested Previously Approved
12/31/1991 12/31/1991 12/31/1988
120,000 0 120,000
10,000 0 10,000
0 0 0

THE INFORMATIO COLLECTED BY USE OF THE FORM SSA-787 IS NEEDED AND USED TO DETERMINE T INDIVIDUAL'S CAPABILITY OR LACK THEREOF IN HANDLING HIS/HER OWN BENEFITS. ALSO THE INFORMATION PROVIDES LEADS FOR THE SOCIAL SECURITY ADMINISTRATION TO FOLLOW IN SELECTING A REPRESENTATIVE PAYEE, IF NEEDED. THE AFFECTED PUBLIC IS COMPRISED OF A PHYSICIAN OF THE BENEFICIARY OR THE MEDICAL OFFICER OF THE INSTITUTION IN WHICH THE

None
None


No

1
IC Title Form No. Form Name
PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT (PATIENT'S CAPABILITY TO MANAGE BENEFITS) SSA-787

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 120,000 120,000 0 0 0 0
Annual Time Burden (Hours) 10,000 10,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/10/1988


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