Authorization to Source to Release Information to the Social Security Administration

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-827 Authorization to Source to Release Information to the Social Security Administration / SSA-827	Form and Instruction	Modified	Available
SSA-827 Addendum 04-04-2007.doc	Supplementary Document	Uploaded 2007-04-04	Available
SSA-827 Supporting Statement 04-04-07.doc	Supporting Statement A	Uploaded 0000-00-00	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9639	Authorization to Source to Release Information to the Social Security Administration / SSA-827	Form and Instruction	Modified
179551	Authorization To Disclose Information To The Social Security Administration / SSA-827		New

ICR Details

OMB Control No: 0960-0623	ICR Reference No: 200704-0960-007
Status: Historical Active	Previous ICR Reference No: 200404-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization to Source to Release Information to the Social Security Administration
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/06/2007
	Date Received in OIRA: 04/11/2007
Terms of Clearance: OMB approves this collection consistent with the e-mail sent by SSA on 6/5/07.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	36 Months From Approved	06/30/2007
Responses	15,415,712	0	15,415,712
Time Burden (Hours)	835,017	0	2,569,285
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA must obtain sufficient medical evidence to make eligibility determinations for title II and title XVI payments. Therefore, the applicant must authorize their medical source(s) to release the information to SSA. The applicant may use form SSA-827 to provide consent for the release of information. Generally, the State DDS completes the form(s) based on information provided by the applicant, and sends the form(s) to the designated medical source(s).

---

Authorizing Statute(s): US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
   US Code: 42 USC 423 Name of Law: null
   US Code: 42 USC 1382c Name of Law: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 3468	01/25/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 14845	03/29/2007
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Authorization To Disclose Information To The Social Security Administration / SSA-827
Authorization to Source to Release Information to the Social Security Administration / SSA-827	SSA-827	Authorization To Disclose Information To The Social Security Administration

---

ICR Summary of Burden

table that charts list of burden

	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	15,415,712	15,415,712	0	0	0	0
Annual Time Burden (Hours)	835,017	2,569,285	0	0	-1,734,268	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The reduction in the public reporting burden is due to a change in the IC burden calculation. Please see the ICR Addendum for a complete explanation.

---

Annual Cost to Federal Government: $23,740,196

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/11/2007

---