Supporting Statement--0024

Supporting Statement for Form SSA-787

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

20 CFR 404.2015 and 416.615

OMB No. 0960-0024

A. Justification

1. If it is not in the best interest of a beneficiary to directly receive Social Security benefits, a relative or other person may act as a representative payee for this beneficiary, as established by Sections 205(j) and 1631(a)(2) of the Social Security Act (the Act). These sections specifically state that if the Commissioner of Social Security deems it appropriate, benefits may be issued to any other person (public or private agency) who is interested in, or concerned with, the welfare of the beneficiary. Sections 20 CFR 404.2015 and 416.615 of the Code of Federal Regulations describe the factors used in determining whether or not to appoint a representative payee. Section 205(a) of the Act gives the Commissioner full power and authority to make rules and regulations, to establish procedures and to adopt reasonable and proper rules for the nature and extent of the evidence as well as the methods of taking and furnishing the same in order to establish the right to benefits.

2. Evidence must be obtained from the beneficiary’s physician before determining whether a representative payee should be appointed for a beneficiary. Therefore, the physician or other medical officer is asked to complete form SSA-787 to provide the Social Security Administration (SSA) with this information. SSA uses the information collected by this form to: a) determine the individual’s capability or lack thereof to handle his/her own benefits and b) to select a representative payee, if needed. The respondents are physicians of the beneficiaries or medical officers of the institution in which the beneficiaries reside.

3. Form SSA-787 is not available electronically. This form is an SSA initiated form, sent to physicians, medical officers or treating sources by field offices with specific information about the beneficiary (i.e., SSN, name and address). Due to the collection of the sensitive information, SSA is hesitant to make this form available electronically until more secure methods are created which will protect the beneficiary over the Internet.

4. The nature of the information being requested and the manner in which it is collected preclude duplication. There is no other collection instrument used by SSA that collects data similar to that collected here.

5. This information collection may involve doctors working in small clinics but will not significantly impact a substantial number of other small businesses or other small entities.

6. The collection of this information is required due to the Agency’s need to determine whether an individual can handle his or her own benefits. Benefits cannot be paid until the beneficiary’s competence is established and a representative payee is selected, if necessary. Therefore, the information could not be collected less frequently. There are no technical or legal obstacles that prevent burden reduction.

7. There are no special circumstances that would cause this information collection to be conducted in a manner inconsistent with 5 CFR 1320.5.

8. The 60-day advance Federal Register Notice was published on February 14, 2007 at 72 FR 7107, and SSA has received no public comments. The second Notice was published on April 23, 2007, at 72 FR 20154. There have been no outside consultations with members of the public.

9. SSA provides no payment or gifts to the respondents.

10. The information requested is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.

11. The information collection contains some questions that may lead to the disclosure of sensitive information, since the beneficiary’s medical history may be disclosed. However, this information is necessary to determine if a beneficiary can receive benefits directly.

12. Form SSA-787 will be completed by approximately 120,000 respondents. The estimated time of completion is 10 minutes. Thus, the total burden is 20,000 hours. The total burden is reflected as burden hours, and no separate cost burden has been calculated.

13. There is no known cost burden to the respondents.

14. The annual cost to the Federal Government is approximately $184,800. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. There are no changes in the public reporting burden.

16. The results of the information collected will not be published.

17. OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB approval. SSA does not periodically revise and reprint its public-use forms, (e.g., on an annual basis). This exemption was granted so that otherwise useable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, Government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.

18. SSA is not requesting an exception to the certification requirements at 5 CFR 1329.0 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

Statistical methods are not used for this information collection.

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