Addendum to Supporting Statement for Form SSA-787
Revisions to the Information Collection
SSA is making the following revisions:
Change #1: We changed the title of the form from “Physician’s/Medical Officer’s Statement of Patient’s Capability to Manage Benefits” to “Medical Source Opinion of Patient’s Capability to Manage Benefits.”
Justification #1: Revisions to Rules and Regulations of Medical Evidence (Federal Register/Vol.82.No.11/January 18, 2017) clarified that:
“statement(s)” about whether an individual has a severe impairment, is a statement on an issue reserved to the Commissioner. We changed the word “Statement” to “Opinion.”
due to rules revisions regarding Acceptable Medical Source (AMS), we changed “Physician’s/Medical Officer’s” to a more general term, “Medical Source”, inclusive of sources who are not physicians but are considered AMS.
Change #2: Under the heading “Your Help is Needed”
Revised the language in the first paragraph: Changed “payments” to “benefits”; deleted “handle funds” and added “manage the Social Security Administration (SSA) benefits on his or her behalf.”
Revised the second sentence of the “Please Note” subheading regarding payment of information.
Justification #2: We made these changes to use more appropriate terms regarding our program and our inability to provide payment for the completion of the form.
Change #3: Corrected the Heading “Who is a Representative Payee” to “What is a Representative Payee”; changed “money” to “SSA benefits”; and added “basic” to “patient’s needs.”
Justification #3: Made these changes for grammatical purposes and clarified that a representative payee only manages SSA benefits. Also, clarified that a representative payee strives to meet the beneficiary’s “basic needs” instead of a broader and undefined “patient’s needs.”
Change #4: Revised the language under the heading “Who Needs a Representative Payee” for clarity and conformity with policy on capability determinations. Changed “senility” to “dementia”; and deleted the word “severe” before brain damage.
Justification #4: We removed sentences that do not conform with existing policy on capability. For example, “dementia” is a more appropriate term than “senility” in discussing disorders that may affect financial capability. We removed the word “severe” in the description of brain damage to reflect that beneficiaries with less severe conditions can still be considered incapable.
Change #5: Question 1. – Changed “Date you last examined the patient” to
“Date you first saw the patient.”
Justification #5: This is a logical first question to assess the duration of a medical source‑patient relationship.
Change #6: Question 2. Deleted the question, “Do you believe the patient is capable of managing or directing the management of benefits in his or her own best interest?” and deleted the two bullets and answer boxes following the question. Replaced the question with, “Date you last saw the patient.”
Justification #6: This is a logical second question to assess the duration of a medical source-patient relationship.
Change #7: Question 3. Deleted the question, “Do you expect the patient to be able to manage funds in the future (for example, the patient is temporarily unconscious)?” and its corresponding answer boxes and space for explanation.
Replaced the question with, “How many times have you seen this patient?”
Justification #7: Knowing the frequency of encounters between the medical source and patient helps in assessing the quality of their relationship. The longer and more frequent the medical source sees the patient, the more they may know about the patient’s capability.
Change #8: Added Questions 4 and 5:
Are you able to assess the patient’s ability to manage or direct the management of funds? Yes__ No___ If no, please skip the remaining questions and sign and date the form.
What is the basis of your assessment (e.g. observation, medical records, diagnostic tests, patient’s self-report, family member’s report)?
Justification #8: Question 4 provides the medical source with the opportunity to state whether they are able to assess the patient’s ability to manage or direct the management of funds. Question 5 provides the basis of the medical source’s assessment.
Change #9: Added the following note to assist the medical source in providing feedback on the patient’s capability: “Note: Please keep in mind in responding to the following questions that the actual performance of the patient, when known, is usually the best indicator of the patient’s abilities.”
In addition, Added Questions 6 and 7 to obtain information related to the patient’s ability to understand finances, handle a checking or savings account, pay bills timely, and successfully manage or direct the management of funds to meet basic needs.
Justification #9: Questions 6 and 7 are screening questions that address whether the beneficiary is capable of managing or directing the management of benefits. The answers to these questions serve as evidence of the beneficiary’s financial performance. We added the note to highlight the importance of answering the questions accurately.
Change #10: Added Question 8, “Do you expect the patient to be able to manage or direct the management of his or her benefits in the future (e.g., the patient is temporarily unconscious)?”
Justification #10: Question 8 is an improved version of previous Question 3, as it clarifies whether the patient can manage or “direct the management of benefits.”
Change #11: Changed “Name of Physician/Medical Officer” to “Name of Medical Source”; and changed “Signature of Physician/Medical Officer” to “Signature of Medical Source.”
Justification #11: “Medical Source” coincides with the term “Medical Source” that is used in the new title of the form.
Change
#12: We
are revising the Privacy Act Statement on this form.
Justification
#12: SSA’s
Office of the General Counsel is conducting a systematic review of
SSA’s Privacy Act Statements on agency forms. As a result,
SSA is updating the Privacy Act Statement on the form.
SSA will implement these changes above upon OMB approval.
These revisions increase the public reporting burden as shown in #12 of the Supporting Statement.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | ADDENDUM TO SUPPORTING STATEMENT |
| Author | Naomi |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |