Medical Source Opinion of Patient’s Capability to Manage Benefits

ICR 202111-0960-006

OMB: 0960-0024

Federal Form Document

Forms and Documents
Supplementary Document
Supporting Statement A
IC Document Collections
ICR Details
0960-0024 202111-0960-006
Received in OIRA 201805-0960-015
Medical Source Opinion of Patient’s Capability to Manage Benefits
Revision of a currently approved collection   No
Regular 11/18/2021
  Requested Previously Approved
36 Months From Approved 12/31/2021
767,737 131,556
255,912 43,852
0 0

SSA collects medical evidence on Form SSA-787 to: (1) determine beneficiaries’ capability or inability to handle their own benefits; and (2) assist in determining the beneficiaries’ need for a representative payee. The respondents are the beneficiary’s physicians or medical officers of the institution in which the beneficiary resides.

US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act

Not associated with rulemaking

  86 FR 47190 08/23/2021
86 FR 64585 11/18/2021

IC Title Form No. Form Name
Medical Source Opinion of Patient's Capability to Manage Benefits SSA-787 Medical Source Opinion of Patient’s Capability to Manage Benefits

  Total Request 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 767,737 131,556 0 0 636,181 0
Annual Time Burden (Hours) 255,912 43,852 0 0 212,060 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
When we last cleared this IC in 2018, the burden was 43,852 hours. However, we are currently reporting a burden of 255,912 hours. This change stems an increase in the number respondents using form SSA-787, and an increase of responses from 131,556 to 767,737. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.

Faye Lipsky 410 965-8783 [email protected]


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:
    (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;
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.

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