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

ICR 199411-0960-004

OMB: 0960-0024

Federal Form Document

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Name
Status
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ICR Details
0960-0024 199411-0960-004
Historical Active 199111-0960-002
SSA
PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT, PATIENT'S CAPABILITY TO MANAGE BENEFITS
Revision of a currently approved collection   No
Regular
Approved without change 01/23/1995
Retrieve Notice of Action (NOA) 11/09/1994
This information collection is approved under the following condition: as indicated in the Justification, SSA needs to change the burden estimate to 10 minutes.
  Inventory as of this Action Requested Previously Approved
03/31/1998 03/31/1998 01/31/1995
120,000 0 120,000
20,000 0 10,000
0 0 0

THE INFORMATION IS USED TO DETERMINE WHETHER AN INDIVIDUAL IS CAPABLE HANDLING HIS/HER BENEFITS. THE INFORMATION IS ALSO USED FOR LEADS IN SELECTING A REPRESENTATIVE PAYEE, IF NEEDED. THE RESPONDENTS ARE PHYSICIANS OF THE BENEFICIARIES OR MEDICAL OFFICERS OF INSTITUTIONS WHERE BENEFICIARIES RESIDE.

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) 20,000 10,000 0 0 10,000 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.
11/09/1994


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