Form SSA-3830 Certification of Low Birth Weight for SSI Eligibility

OMB No. 0960-0720

Certification of Low Birth Weight for SSI Eligibility
For SSA Use Only
Requester

Office address

Phone #

Fax #

1) Child’s SSN (if available) _____________________________________________
2) Child’s name: _______________________________________________________ Female  Male 
First
Middle
Surname
3) Medical record #: ____________________________________________________
4) Parents: Mother’s name: _______________________________________________________
First
Maiden
Surname
Father’s name: _________________________________________________________
First
Surname
Phone # ___________________

Address ___________________________________

5) Hospital of birth: ________________________
6) Date of birth:_________________________
7) Weight at birth: __________________grams
8) Gestational age (GA) at birth:_______ weeks
9) Medical conditions (check all that apply):
 Cerebral white matter insult (periventricular leukomalacia, intraventricular hemorrhage (IVH)
grade 3-4, or ventriculomegaly)
 Bronchopulmonary Dysplasia (BPD), also known as Chronic Lung Disease (CLD) of
prematurity
 Retinopathy of Prematurity (ROP), grade 3 or greater
 Necrotizing Enterocolitis (NEC), requiring bowel resection surgery
 Other (please specify): __________________________________________________
_______________________________________________________________________
10) Date of discharge (if applicable): ___________Released to (person/facility): ____________________
11) Name and phone number of hospital social worker who can provide information about this child:
Name: _________________________________________Phone: ___________________

OPTIONAL: Attach copy of admission, discharge summary, or other medical evidence.
-OVER-

SSA-3830

I certify that the foregoing information is accurate according to the child’s medical records.
Physician signature: ____________________________________________
Title: ____________
Date: ____________
Print or type name: ______________________________________________________________
Hospital: ______________________________________________________________________
Address: ______________________________________________________________________
PLEASE RETURN THE COMPLETED FORM TO THE SOCIAL SECURITY FIELD OFFICE
SHOWN ON TOP OF PAGE ONE
The Privacy and Paperwork Reduction Acts
The Social Security Administration is authorized to collect the information on this form under sections
1614 and 1633 of the Social Security Act. Social Security needs this information to make a decision on
the named claimant’s claim under 20 CFR sections 416.931, 416.926a(m), and 416.924. While giving us
the information on this form is voluntary, failure to provide all or part of the requested information could
prevent an accurate or timely decision on the named claimant’s claim. Although the information you
furnish is almost never used for any purpose other than making a determination about the claimant’s
disability, such information may be disclosed by the Social Security Administration as follows: (1) to
enable a third party or agency to assist Social Security in establishing rights to Social Security benefits
and/or coverage; (2) to comply with Federal Laws requiring the release of information from Social
Security records (e.g., to the General Accounting Office and the Department of Veterans Affairs); and (3)
to facilitate statistical research and such activities necessary to assure the integrity and improvement of
the Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to
Social Security).
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies may
use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it. Explanations about these and
other reasons why information you provide us may be used or given out are available in Social Security
offices. If you want to learn more about this, contact any Social Security office. See Revised PA
Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. § 3507,
as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless
we display a valid Office of Management and Budget control number. We estimate that it will take 10 – 15 minutes
to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR
NEAREST SOCIAL SECURITY OFFICE OR TO THE SOCIAL SECURITY OFFICE THAT REQUESTED IT. If
you have questions about how to complete the form, contact the Social Security office nearest you or the Social
Security office that requested it. If you need the address or phone number for your nearest Social Security office,
you can get it by calling Social Security at 1-800-772-1213. You may send comments on our time estimate above to:
SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.

See Revised Paperwork
Reduction Act Statement

SSA-3830

The following revised Privacy Act Statement will be inserted into the form at its next scheduled
reprinting:
The Privacy and Paperwork Reduction Acts
PRIVACY ACT NOTICE: Sections 1614 and 1633 of the Social Security Act, as amended, and Social Security
regulations at 20 C.F.R. §§ 416.931, 416.926a(m)(6) and 416.924 authorize us to collect this information. The
information is needed to determine benefit eligibility of the named claimant. The information you furnish on this
form is voluntary. However, failure to provide all or part of the information could prevent an accurate and timely
decision on benefit eligibility of the named claimant.
We rarely use the information you supply for any purpose other than for establishing benefit eligibility. However,
we may use it for the administration and integrity of Social Security programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but are not limited to:
(1) to enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits
and/or coverage; (2) to comply with Federal laws requiring the release of information from Social Security records
(e.g., to the Government Accountability Office and Department of Veteran Affairs); (3) to make determinations for
eligibility in similar health and income maintenance programs at the Federal, State, and local level; (4) to State
agencies or other agencies providing services to disabled children; and (5) to facilitate statistical research, audit or
investigative activities necessary to assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our
records with records kept by other Federal, state or local government agencies. Information from these matching
programs can be used to establish or verify a person’s eligibility for Federally funded and administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Records Notice 60-0103 (Supplemental
Security Income Record and Special Veterans Benefits). The notice, additional information regarding this form, and
information regarding our programs and systems, are available on-line at www.ssa.gov or at your local Social
Security office.
Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. § 3507,
as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless
we display a valid Office of Management and Budget control number. We estimate that it will take 10 – 15 minutes
to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR
NEAREST SOCIAL SECURITY OFFICE OR TO THE SOCIAL SECURITY OFFICE THAT REQUESTED IT. If
you have questions about how to complete the form, contact the Social Security office nearest you or the Social
Security office that requested it. If you need the address or phone number for your nearest Social Security office,
you can get it by calling Social Security at 1-800-772-1213. You may send comments on our time estimate above to:
SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.

SSA-3830