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

Form Approved
OMB No. 0960-0024

TOE 250

SOCIAL SECURITY ADMINISTRATION

PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT OF PATIENT'S CAPABILITY TO MANAGE BENEFITS
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U. In replying, use this address:
S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to SOCIAL SECURITY ADMINISTRATION
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. You can find your local Social Security office through SSA's website at
www.socialsecurity.gov. Offices are also 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).
Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.
TELEPHONE NUMBER (Including Area Code)

(

)

-

DATE

Privacy Act Statement
SSA CONTACT

Sections 205(a) and 205(j), of the Social Security Act, as amended, authorize 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 IDENTIFYING INFORMATION (SSA Only)
If different from patient
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 NAME OF WAGE EARNER OR SELFbenefits and/or coverage; (2) to comply with Federal laws requiring the release of information EMPLOYED PERSON
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.
SOCIAL SECURITY NUMBER
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.socialsecurity.gov or at your
local 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 (05-2010) ef (05-2010) Destroy Prior Editions

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

PATIENT'S NAME
PATIENT'S SOCIAL SECURITY NUMBER

-

-

PATIENT'S DATE OF
BIRTH

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.
SIGNATURE OF PHYSICIAN/
MEDICAL OFFICER
Form SSA-787 (05-2010) ef (05-2010)

DATE

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 205(j) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to make a determination regarding the
claimant’s need for a representative payee.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding management of benefits. However, we may use the information for the administration
of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notices 60-0089, entitled Claims Folders Systems; and, 60-0222,
entitled Master Representative Payee File. Additional information about these and other system
of records notices and our programs is available online at www.socialsecurity.gov or at your
local Social Security office.
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 or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.