Treating Physician Consultative Examination Interest Form

Forms and Documents

Document	Type	Status	Availability
Form SSA-84 Treating Physician Consultative Examination Interest Form	Form	Modified	Available
Supporting Statement (revised).doc	Supporting Statement A	Uploaded 2010-05-18	Available
MER letter.tif	Supplementary Document	Uploaded 2010-03-23	Repair queued
Addendum--SSA-84[1].doc	Supplementary Document	Uploaded 2010-05-13	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
179601	Treating Physician Consultative Examination Interest Form	Form	Modified

ICR Details

OMB Control No: 0960-0751	ICR Reference No: 201002-0960-012
Status: Historical Active	Previous ICR Reference No: 200704-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: Treating Physician Consultative Examination Interest Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/22/2010
	Date Received in OIRA: 05/18/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2013	36 Months From Approved	09/30/2010
Responses	168	0	168
Time Burden (Hours)	14	0	14
Cost Burden (Dollars)	0	0	0

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Abstract: When an applicant for Social Security disability benefits has not consulted a physician for a specified period preceding the application, SSA will ask the applicant to complete a consultative exam (CE). If the applicant has a treating physician (TP), SSA mails a medical evidence of record request letter and Form SSA-84 to the applicant’s TP; the TP completes the latter form and mails it to SSA to indicate interest in conducting the CE. If the TP does not return the form, SSA assumes the TP is not interested in performing the CE. Respondents are disability benefits applicants' treating physicians.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 9992	03/04/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 27036	05/13/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Treating Physician Consultative Examination Interest Form	SSA-84	Treating Physician Consultative Examination Interest Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	168	168	0	0	0	0
Annual Time Burden (Hours)	14	14	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $259

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/18/2010

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