Form SSA-787 Physician's/Medical Officer's Statement of Patient's Cap

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No.0960-0024

TOE 250

PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT OF PATIENT'S CAPABILITY TO MANAGE BENEFITS
In replying, use this address:
SOCIAL SECURITY ADMINISTRATION
Paperwork Reduction Act Statement - This information collection meets the requirements of 44
U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need
to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and
answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
To find the nearest office, call 1-800-772-1213. Send only comments on our time estimate above to:
SSA, 1338 Annex Building, Baltimore, MD 21235-6401.

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TELEPHONE NUMBER (Include Area Code)

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DATE
SSA CONTACT

Privacy Act: This report is authorized by sections 205(a) and 205(j) of the Social Security
Act, as amended (42 U.S.C. 405(a) and 405(j). While you are not required to respond,
your cooperation will help us decide whether any Social Security benefits that may be due IDENTIFYING INFORMATION (SSA Only)
should be paid directly to the patient or to someone else on the patient's behalf. Your If different from patient
cooperation in completing and returning this statement will be appreciated.
NAME OF WAGE EARNER OR SELF-

We may also use the information you give us when we match records by computer. EMPLOYED PERSON
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove that a
person qualifies for benefits paid by the Federal government. The law allows us to do this SOCIAL SECURITY NUMBER
even if you do not agree to it. Explanations about these and other reasons why
information you provide may be used or given out are available in Social Security Offices.
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If you want to learn more about this, contact any Social Security Office.
PATIENT'S NAME

PATIENT'S ADDRESS (Number and Street, City, State, and ZIP Code)

PATIENT'S SOCIAL SECURITY NUMBER

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PATIENT'S DATE OF
BIRTH

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YOUR HELP IS NEEDED
The patient shown above has filed for or is receiving Social Security or Supplemental Security
Income payments. We need you to complete the back of this form and return it to us in the
enclosed envelope to help us decide if we should pay this person directly or if he or she needs a
representative payee to handle the funds. Please Note: This determination affects how benefits
are paid and has no bearing on disability determinations. Thank you for your help.
WHO IS A REPRESENTATIVE PAYEE
A representative payee is someone who manages the patient's money to make sure the patient's
needs are met. The payee has a strong and continuing interest in the patient's well-being and is
usually a family member or close friend.
WHO NEEDS A REPRESENTATIVE PAYEE
Some individuals age 18 and older who have mental or physical impairments are not capable of
handling their funds or directing others how to handle them to meet their basic needs, so we
select a representative payee to receive their payments. Examples of impairments which may
cause incapability are senility, severe brain damage or chronic schizophrenia. However, even
though a person may need some assistance with such things as bill paying, etc., does not
necessarily mean he/she cannot make decisions concerning basic needs and is incapable of
managing his/her own money.
PLEASE COMPLETE THE INFORMATION ON THE REVERSE OF THIS FORM
Form SSA-787 (09-2004) EF (12-2004) Destroy Prior Editions

1. Date you last examined the patient

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2. Do you believe the patient is capable of managing or directing the management of benefits in his or her own best interest?
By capable we mean that the patient:
z Is able to understand and act on the ordinary affairs of life, such as providing for own adequate food,
housing, clothing, etc., and
z Is able, in spite of physical impairments, to manage funds or direct others how to manage them.
Yes

No

If "Yes", please omit
question 3, but be sure to
sign and date the form.

Unsure

If "No", please provide a brief summary
of the findings that led to this conclusion.
Also, complete question 3.

If "unsure",
please explain.

3. Do you expect the patient to be able to manage funds in the future (for example, the patient is temporarily unconscious)?
Yes

No

If yes, please explain.

NAME OF PHYSICIAN/MEDICAL OFFICER (Please print.)

ADDRESS (Number and street, City, State, and ZIP Code)

TITLE

TELEPHONE NUMBER (Include Area Code)

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I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or
misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
sent to prison, or may face other penalties, or both.
SIGNATURE OF PHYSICIAN/MEDICAL OFFICER
Form SSA-787 (09-2004) EF (12-2004)

DATE