Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits

ICR 200703-0960-004

OMB: 0960-0024

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
0960-0024 200703-0960-004
Historical Active 200404-0960-005
SSA
Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits
Revision of a currently approved collection   No
Regular
Approved without change 08/02/2007
Retrieve Notice of Action (NOA) 05/07/2007
This ICR is approved for 2 years only. Upon resubmission, SSA will explore the feasibility of providing physicians and medical officers an electronic version of this form, particularly in light of the direction towards electronic records that SSA is moving towards. Though a fully-downloadable form may not be feasible due to privacy and fraud concerns, SSA should nevertheless consider creating something like a fillable PDF form, which SSA can send directly to respondents and which respondents may find more useful than a paper form.
  Inventory as of this Action Requested Previously Approved
08/31/2009 36 Months From Approved 08/31/2007
120,000 0 120,000
20,000 0 20,000
0 0 0

The information collected on the SSA-787 is used to determine whether an individual is capable of handling his or her own benefits. This information is also used for leads in selecting a representative payee, if needed. The respondents are physicians of the beneficiaries or medical officers of the institution in which the beneficiaries reside.

US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
  
None

Not associated with rulemaking

  72 FR 7107 02/14/2007
72 FR 20154 04/23/2007
No

  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 20,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$184,800
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Elizabeth Davidson 411-965-0454 [email protected]

  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.
05/07/2007


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