Medical Source Opinion of Patient's Capability to Manage Benefits

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, 807, and 1631(a) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from making a determination regarding the beneficiary’s
capability or inability to handle his or her own benefits.
We will use the information to determine the beneficiary’s need for a representative payee. We
may also share your information for the following purposes, called routine uses:
•

To Federal, State, or local agencies for administering cash or non-cash income
maintenance or health maintenance programs; and

•

To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0222, entitled Master Representative Payee File, as
published in the FR on April 22, 2013, at 78 FR 23811. Additional information, and a full listing
of all our SORNs, is available on our website at www.ssa.gov/privacy.

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 20
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). You may send comments regarding this burden estimate or any other
aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate or other aspects of this collection to this address, not the completed form.