Information Collection

Medical Source Opinion of Patient's Capability to Manage Benefits

IC 8918 under ICR 202111-0960-006 · OMB 0960-0024.

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
Form SSA-787 Medical Source Opinion of Patient’s Capability to Manage Benefits Medical Source Opinion of Patient's Capability to Manage Benefits	Form
Revised PA Statement and PRA Statement.pdf	Other-Revised PA Statement
Revised PA Statement and PRA Statement.pdf	Other-Revised PA Statement
SSA-787 Medical Source Opinion of Patient’s Capability to Manage SSA-787 (revised).pdf	Form
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
SSA-787 (current).pdf Current SSA-787	IC Document

IC Title:

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				Yes	No	Fillable Printable
Other-Revised PA Statement					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: 767,737

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	767,737	636,181	131,556
Annual IC Time Burden (Hours)	255,912	212,060	43,852
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-787		05/24/2024

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

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