Information Collection

Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits

IC 8918 under ICR 200812-0960-003 · OMB 0960-0024.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0024 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-787 Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits	Form
SSA-787 Physician's/Medical Officer's Statement of Patient's Cap ssa787 revised.pdf	Form

IC Title:

Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.615 20 CFR 404.2015

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-787				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	120,000	120,000
Annual IC Time Burden (Hours)	20,000	20,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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