Supporting Statement for OMB Clearance for the SSA-91
Request to Release Medical Report to a Health Care Provider Form
20 CFR 401.55 & 401.100
0960-NEW
A. Justification
20 CFR 401.100 of the Code of Federal Regulations governs the Social Security Administration’s (SSA) policy of disclosing an individual’s record with written consent. This regulation is applicable to the claimant’s right to request the release of a consultative examination (CE) report to a health care provider. This regulation does not authorize the parent/legal guardian to give consent to a disclosure of the minor’s medical record (20 CFR 401.100(b)). However, 20 CFR 401.55(2) provides for disclosure to a family doctor or other health professional when a parent/legal guardian acting on the minor’s behalf wants access to a minor’s record. To gain access to a minor’s record, the parent/legal guardian must designate a physician or other health professional to first receive the record (20 CFR 401.55). The health care provider designated by the parent or legal guardian may then review and discuss the medical records and/or the CE report with the parent/legal guardian and provide a copy of it to him/her.
Form SSA-91, the Request to Release Medical Report to a Health Care Provider form, is sent to the claimant or the parent/legal guardian with the CE appointment notice and the SSA-104, Claimant Travel Reimbursement Request. If the claimant or the parent/legal guardian wants the CE report sent to the claimant’s health care provider, he or she will complete the information requested on the form, including the health care provider’s name and address, sign the form and send it to SSA. SSA will use the information collected to send the CE report to the designated health care provider.
Because the collection of this information is initiated by SSA, no electronic method is used to collect it. The claimant or parent/legal guardian is notified by mail of the consultative examination and the SSA-91 is sent with that notification. The paper form is completed and returned to SSA via mail. SSA currently has no plans to make this form available electronically due to the low volume of requests to release the CE report to a health care provider.
The SSA-3288 (OMB Control No. 0960-0566) is also used as a medical release form; however, it cannot be used to release a minor’s medical records. According to 20 CFR 401.55 (c)(2)(ii) and (iii), a parent or legal guardian making a request for a minor’s medical records does have the authority to designate a physician or other health professional to receive the minor’s medical records. The SSA-91 was created so the claimant or claimant's parent/legal guardian can request SSA to send a copy of the CE report to the claimant's physician or other health care professional. Since the SSA-3288 cannot be used to authorize disclosure of a minor's CE or other medical report to his/her health care provider and is used for more general disclosure purposes (i.e., for all types of SSA records) it does not serve the same purpose as the SSA-91. The SSA-3288's limitations prevent us from using it as an authorization form to release a minor’s CE report to a health care provider. Also, 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 its own forms and procedures to collect the same information we are asking for on the SSA-91. 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.
This collection does not impact small businesses or other small entities.
If this information were not collected then SSA would not be following the law allowing the claimants to request the release of the medical report to their physicians. Also, because these forms are only sent out when SSA sends the notification of a consultative examination, the information cannot be collected less frequently. There are no technical or legal obstacles that prevent burden reduction.
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.
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 21, 2007, at 72 FR 28540. There have been no outside consultations with members of the public.
SSA provides no payment or gifts to the respondents.
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.
The information collection does not contain any questions of a sensitive nature.
SSA estimates that there are 7,922 respondents responding once annually. Each response takes approximately 5 minutes to read the instructions, gather the facts, and answer the questions. Therefore, the total annual burden to the public will be approximately 660 hours. The total burden is reflected as burden hours and no separate cost burden has been calculated.
There is no known cost burden to the respondents.
The annual cost to the Federal Government is approximately $12,200. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
This is an information collection in use without an OMB control number that will increase the public reporting burden.
The results of the information collection will not be published.
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.
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.
| File Type | application/msword |
| File Title | Supporting Statement for OMB Clearance for |
| Author | Joseph Karevy 6-1483 |
| Last Modified By | 177717 |
| File Modified | 2007-11-20 |
| File Created | 2007-11-20 |