Form SSA-787 Physician's/Medical Officer's Statement of Patient's Cap

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No.0960-0024

TOE 250

PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT OF PATIENT'S CAPABILITY TO MANAGE BENEFITS
Paperwork Reduction Act Statement - This information collection meets the requirements In replying, use this address:
of 44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You SOCIAL SECURITY ADMINISTRATION
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 about 10 minutes to read the
instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM
TO YOUR LOCAL SOCIAL SECURITY OFFICE. To find the nearest office, call
1-800-772-1213. Send only comments on our time estimate above to: SSA, 1338 Annex
Building, Baltimore, MD 21235-6401.

See Revised Paperwork
Reduction Act Statement

TELEPHONE NUMBER (Including Area Code)

(

)

-

DATE

See Revised Privacy Act
Statement

SSA CONTACT

Privacy Act: This report is authorized by sections 205(a) and 205(j) of the Social Security Act,
as amended (42 U.S.C. 405(a) and 405(j). While you are not required to respond, your
cooperation will help us decide whether any Social Security benefits that may be due should be IDENTIFYING INFORMATION (SSA Only)
paid directly to the patient or to someone else on the patient's behalf. Your cooperation in If different from patient
completing and returning this statement will be appreciated.
NAME OF WAGE EARNER OR SELF-

We may also use the information you give us when we match records by computer. Matching EMPLOYED PERSON
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 SOCIAL SECURITY NUMBER
agree to it. Explanations about these and other reasons why information you provide 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.
PATIENT'S NAME

PATIENT'S ADDRESS (Number and Street, City, State, and ZIP Code)

PATIENT'S SOCIAL SECURITY NUMBER

-

PATIENT'S DATE OF
BIRTH

-

YOUR HELP IS NEEDED
The patient shown above has filed for or is receiving Social Security or Supplemental Security Income
payments. We need you to complete the back of this form and return it to us in the enclosed envelope
to help us decide if we should pay this person directly or if he or she needs a representative payee to
handle the funds. Please Note: This determination affects how benefits are paid and has no bearing
on disability determinations; SSA will NOT pay for this information. Thank you for your help.
WHO IS A REPRESENTATIVE PAYEE
A representative payee is someone who manages the patient's money to make sure the patient's
needs are met. The payee has a strong and continuing interest in the patient's well-being and is
usually a family member or close friend.
WHO NEEDS A REPRESENTATIVE PAYEE
Some individuals age 18 and older who have mental or physical impairments are not capable of
handling their funds or directing others how to handle them to meet their basic needs, so we select a
representative payee to receive their payments. Examples of impairments which may cause
incapability are senility, severe brain damage or chronic schizophrenia. However, even though a
person may need some assistance with such things as bill paying, etc., does not necessarily mean
he/she cannot make decisions concerning basic needs and is incapable of managing his/her own
money.
PLEASE COMPLETE THE INFORMATION ON THE REVERSE OF THIS FORM
Form SSA-787 (09-2004) ef (12-2004) Destroy Prior Editions

1. Date you last examined the patient
2. Do you believe the patient is capable of managing or directing the management of benefits in his or her own best interest?
By capable we mean that the patient:
•

Is able to understand and act on the ordinary affairs of life, such as providing for own adequate food, housing,
clothing, etc., and

• Is able, in spite of physical impairments, to manage funds or direct others how to manage them.
No

Yes
If "Yes", please omit
question 3, but be sure to
sign and date the form.

Unsure
If "unsure",
please explain.

If "No", please provide a brief summary
of the findings that led to this conclusion.
Also, complete question 3.

3. Do you expect the patient to be able to manage funds in the future (for example, the patient is temporarily unconscious)?
Yes

No

If yes, please explain.

NAME OF PHYSICIAN/MEDICAL OFFICER (Please print.)

ADDRESS (Number and street, City, State, and ZIP Code)

TITLE

TELEPHONE NUMBER (Include Area Code)

(

)

-

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or
misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
sent to prison, or may face other penalties, or both.
DATE
SIGNATURE OF PHYSICIAN/
MEDICAL OFFICER
Form SSA-787 (09-2004) ef (12-2004)

The following revised Privacy Act Statement will be inserted into the form at its next
scheduled reprinting:

Privacy Act Statement
Sections 205(a) and 205(j), of the Social Security Act, as amended, authorizes us to
collect this information. The information is needed to make a determination regarding
whether or not the named individual should be paid benefits directly or whether benefits
should be paid to a representative payee. 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 the proper payee for benefit receipt purposes.
We rarely use the information you supply for any purpose other than for making a
determination on a claim. 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; and (4) 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 Systems of Record
Notices 60-0089 and 60-0222. The notices, 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.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 about 10
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.