Addendum to the Supporting Statement for 0960-0052

Addendum to the Supporting Statement for Form SSA‑3826

Medical Report (General)

20 CFR 404.1512-404.1515 and 416.912-416.915

OMB No. 0960-0052

Revisions to the Collection Instrument

• Privacy Act Statement

  • In the Privacy Act Statement, we changed section 223(d) of the Social Security Act to section 223(d)(5)(A), which is the more complete citation shown on our other forms, and changed the citation of section 1631(e)(1) to section 1631(d)(1), which is the correct citation.

• Identifying Information – Page 1

  • The current form SSA-3826 requires the name of the doctor. We changed the heading in this part to ask for the name of the medical source. This change reflects the fact that the form SSA-3826 is used to request information from medical sources other than doctors, e.g., hospital medical records librarians, physical therapists, nurse practitioners.

  • For the same reason, in the notice box, we changed “NOTICE TO PHYSICIAN,” to “NOTICE TO MEDICAL SOURCE.”

  • In the notice, we changed “REVIEWING PHYSICIAN” to “REVIEWING MEDICAL CONSULTANT.”

    • The reviewing medical consultant is not always a physician, but may be a psychologist, optometrist, podiatrist, or qualified speech-language pathologist.

• Part II. – Medical Findings – Page 2

  • We changed the heading of this part from “PHYSICAL FINDINGS,” to the more general “MEDICAL FINDINGS” to reflect the fact that form SSA-3826 can be used by a medical source to report either physical or mental findings.

• Part III. – Laboratory and Special Studies - Page 3

  • In the instructional sentence, we changed the language in the parenthetical.

    • When studies include an electrocardiogram(s) (ECGs), we need a copy of the tracing(s). We cannot accept a detailed description of the test results in lieu of the actual tracing. Therefore, the phrase, “or a detailed description thereof’ has been deleted.

    • The same rule applies to reports of pulmonary function studies (PFS); we need a copy of the actual tracing. We have added “and PFSs” to the parenthetical.

    • We have deleted the apostrophe in ECGs to conform to the Government Printing Office style manual rule for use of apostrophes. The intent is to refer to multiples of the tests.

• Part VI. – Ability to Manage Funds - Page 4

  • We have added a new Part VI. This part is to be completed by the medical source when a mental impairment is diagnosed.

  • The medical source is asked to provide an opinion as to whether the patient is able to manage his or her own funds.

  • In the event we find the person disabled, we will use this information to determine if the person can be paid on his own behalf or whether we need to consider designating a representative payee.

  • The language in the question follows that used on our other forms to request the same information. The medical source is asked to check either the “YES” or “NO” block and to provide an explanation for a “NO” opinion.

• Name and Identifying Information About the Medical Source Who Completed the Form – Page 4

  • In the box requesting the name and address of the medical source who completed the form, we changed “PHYSICIAN’S NAME” to “MEDICAL SOURCE’S NAME” for the same reason we changed “physician” to “medical source” elsewhere on the form.

  • The form can be completed by any medical source, not just a physician.

Most of the changes we are making merely bring the language on the form into compliance with the way in which the form is used. However, the current form will continue to be used until existing supplies are depleted.