Information Collection

Medical Source Opinion of Patient's Capability to Manage Benefits

IC 8918 under ICR 201805-0960-015 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Medical Source Opinion of Patient's Capability to Manage Benefits	Form
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-787 Medical Source Opinion of Patient’s Capability to Manage SSA-787 - Revised.pdf	Form
SSA-787 - Current.pdf Current SSA-787	IC Document

IC Title:

Medical Source Opinion 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 404.2015 20 CFR 416.615

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	Medical Source Opinion of Patientâs Capability to Manage Benefits	SSA-787 - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 131,556

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	131,556	11,556	120,000
Annual IC Time Burden (Hours)	43,852	23,852	20,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-787	SSA-787 - Current.pdf	08/14/2018

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