Supporting Statement--SSA-84

Supporting Statement for OMB Clearance for the SSA-84

Treating Physician Consultative Examination Interest Form

20 CFR 404.1519g-i

0960-NEW

A. Justification

1. 20 CFR 404.1519g, 404.1519h, and 404.1519i of the Code of Federal Regulations states that the individual’s treating physician (TP) is the preferred source to perform a consultative examination (CE). The method by which the Social Security Administration (SSA) ascertains whether the TP is interested in performing the CE is through the collection of information on the SSA-84.

2. Form SSA-84, Treating Physician Consultative Examination Interest Form, is used to determine if the TP is qualified, equipped and willing to perform the consultative examination and/or tests. This form is sent to the claimant’s treating physician with the medical evidence of record (MER) request letter (0960-0555) and a completed SSA-91, Authorization to Release Medical Report to Physician. If the treating physician is interested in performing the CE he or she will indicate interest by completing the form and returning it to SSA. If the treating physician does not return the form, SSA assumes that he or she is not interested in performing a CE. Respondents are the doctors of SSA claimants.

3. As this is an SSA-initiated process, no electronic method is used to collect this information. The treating physician is mailed the SSA-84 along with the MER request letter. The paper form is completed and returned to SSA via mail. Because of the extremely low volume of respondents, and the fact that SSA initiates the collection of information, there are currently no plans to make the SSA-84 available electronically.

4. While similar information is collected through the state DDS forms approved under OMB Control No. 0960-0555, SSA requires Federal versions of the forms in order to assist the state DDSs with their disability claims workloads. Each State we assist has their own forms and procedures to collect the same information we are asking for on the SSA-84. However, as a federal component, we do not have the authority to use the State's forms. Since we assist many States with their disability workloads, we need standardized federal forms that can be used in any State we assist.

5. This collection does not have a significant impact on a substantial number of small businesses or other small entities.

6. If this information were not collected, SSA would be unable to determine whether or not the claimants’ TPs are willing and capable of conducting the CE. Because the information is only collected on a voluntary basis, it cannot 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 that is not consistent 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 May 9, 2007, at 72 FR 26443. 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 does not contain any questions of a sensitive nature.

12. SSA estimates that 168 TPs will each respond once annually. We estimate each respondent will take 5 minutes to read the instructions, gather the facts, and answer the questions. Therefore, the total annual burden to the public will be approximately 14 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 $259. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. This is an information collection in use without an OMB control number that will increase the public reporting burden.

16. The results of the information collection 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 1320.9 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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