Supporting Statement for Form SSA-787
Physician’s/Medical Officer’s Statement of Patient’s Capability to Manage Benefits
20 CFR 404.2015 and 416.615
OMB No. 0960-0024
A. Justification
1. If it is not in the best interest of a beneficiary to directly receive Social Security benefits, a relative or other person may act as a representative payee for this beneficiary, as established by Sections 205(j) and 1631(a)(2) of the Social Security Act (the Act). These sections specifically state that if the Commissioner of the Social Security Administration (SSA) deems it appropriate, SSA may issue benefits to any other person (public or private agency) who is interested in, or concerned with, the welfare of the beneficiary. Sections 20 CFR 404.2015 and 416.615 of the Code of Federal Regulations describe the factors used in determining whether to appoint a representative payee. Section 205(a) of the Act gives the Commissioner full power and authority to make rules and regulations, to establish procedures and to adopt reasonable and proper rules for the nature and extent of the evidence as well as the methods of taking and furnishing the same in order to establish the right to benefits.
2. SSA must obtain evidence from the beneficiary’s physician before determining whether a beneficiary needs a representative payee. Therefore, SSA asks the physician or other medical officer to complete form SSA-787 to provide SSA with this information. SSA uses the information collected by this form to: a) determine the individual’s capability or lack thereof to handle his/her own benefits and b) select a representative payee, if needed. The respondents are physicians of the beneficiaries or medical officers of the institution in which the beneficiaries reside.
3. Form SSA-787 is not available electronically. This form is an SSA-initiated form, sent to physicians, medical officers or treating sources by field offices with specific information about the beneficiary (i.e., SSN, name and address). Due to the collection of the sensitive information, SSA is hesitant to make this form available electronically until SSA can create a more secure method, which will protect the beneficiary over the Internet. However, a PDF file does exist for internal access by SSA personnel.
4. The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to collect similar data.
5. This information collection may involve doctors working in small clinics but will not significantly affect a substantial number of other small businesses or other small entities.
6. SSA requires the collection of this information due to the Agency’s need to determine whether an individual can handle his or her own benefits. SSA cannot pay benefits until the beneficiary’s competence is established and if necessary, a representative payee is appointed. Therefore, SSA cannot collect this information less frequently. There are no technical or legal obstacles to prevent burden reduction.
7. There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
The 60-day advance Federal Register Notice published on January 15, 2009, at 74 FR 2642, and SSA received no public comments. The second Notice published on March 19, 2009, at 74 FR 11804. If we receive comments in response to the 30-day notice, we will forward them to OMB. SSA did not consult members of the public in the development of this form.
9. SSA provides no payment or gifts to the respondents.
10. SSA protects and holds confidential the information it is requesting 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 contains some questions that may lead to the disclosure of sensitive information since the beneficiary's medical history may be included in the collection. However, this information is necessary to determine if a beneficiary can receive benefits directly.
12. Approximately 120,000 respondents use this form. The estimated completion time is 10 minutes. Thus, the total burden is 20,000 hours. The total burden represents burden hours, and SSA did not calculate a separate cost burden.
13. There is no known cost burden to the respondents.
14. The annual cost to the Federal Government is approximately $184,800. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. There are no changes in the public reporting burden.
16. SSA will not publish the results of the information collection.
17. OMB has granted SSA an exemption from the requirement that the OMB exempted SSA from the requirement to print the OMB approval expiration date 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). SSA granted this exemption so the agency would not have to discontinue using otherwise useable editions of forms with outdated expiration dates. In addition, SSA avoids Government waste, because we will not have to destroy and reprint stocks of forms.
18. SSA is not requesting an exception to the certification requirements at 5 CFR 1329.0 and related provisions at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
SSA is not using statistical methods for this collection.
| File Type | application/msword |
| Author | 152290 |
| Last Modified By | Davidson, Liz |
| File Modified | 2009-05-06 |
| File Created | 2009-05-06 |