Medical Source Opinion of Patient's Capability to Manage Benefits

Medical Source Opinion of Patient’s Capability to Manage Benefits

Documents and Forms

Document Name Document Type
Form SSA-787 Medical Source Opinion of Patient's Capability to Manage Benefits Form
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 (current).pdf Current SSA-787 IC Document

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-787	Medical Source Opinion of Patient’s Capability to Manage Benefits	SSA-787 (revised).pdf		Yes	No	Fillable Printable
Other-Revised PA Statement			Revised PA Statement and PRA 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: 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 %

	Requested	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

Title	Document	Date Uploaded
Current SSA-787	SSA-787 (current).pdf	11/15/2021

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