Title of Information Collection and Form Number(s)

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Supporting Statement for 
Statement From Excluded Medical Sources of Evidence 
20 CFR 404.1503b and 416.903b
OMB No. 0960-0803

A. 	Justification

    1. Introduction/Authoring Laws and Regulations
Section 812 of the Bipartisan Budget Act of 2015 (BBA), “Exclusion of certain medical sources of evidence,” mandates that the Social Security Administration (SSA) exclude evidence in disability decisions from certain medical sources.  BBA Section 812 amended section 223(d)(5) of the Social Security Act (Act) by adding a subsection “C.”  

Section 223(d)(5)(C)(i) of the Act, as amended, requires SSA to exclude evidence (except for good cause) from medical sources:  (1) convicted of a felony under Sections 208 or 1632 of the Act; (2) excluded from participating in any Federal health care program under section 1128 of the Act; or (3) imposed with a civil monetary penalty (CMP), assessment, or both, for submitting false evidence, under Section 1129 of the Act.

Pursuant to its broad authority to regulate under Sections 205(a), 702(a)(5), and 1631(d)(1) of the Act, SSA implemented Section 223(d)(5)(C), as amended, through regulations at 20 CFR 404.1503b and 416.903b of the Code of Federal Regulations.  These regulations require excluded medical sources to self-report their excluded status, in writing, each time they submit evidence related to a claim for benefits under Titles II or XVI of the Act.  Excluded medical sources’ duty to self-report their excluded status applies to evidence they submit to SSA directly, or through a representative, claimant, or other individual or entity.

    2. Description of Collection
SSA informs the medical sources we suspect should be excluded of these requirements through a Fact Sheet (our initial notice to them).  The Fact Sheet explains the medical source’s duty to self-report their excluded status by attaching a statement to any evidence they submit to SSA.  If we later receive evidence from these medical sources that does not include the required statement self-reporting their excluded status, we also send the medical sources a follow-up notice to remind them that they must self-identify as an excluded source.  We send both the Fact Sheet and follow-up notice via mail.  In addition, through our website, we list the regulatory requirements under BBA Section 812 and provide sample statements as templates which the affected medical sources can use to create their own written statements.  

The following regulatory sections describe and contain the public reporting burdens for this collection:

    • 20 CFR 404.1503b – This regulatory section requires sources excluded by section 223(d)(5)(C)(i) of the Act, as amended, to self-report their exclusion, in writing, each time they submit evidence related to a claim for initial or continuing benefits under Titles II or XVI of the Act.  This duty applies to evidence submitted to SSA directly, or through a representative, claimant, or other individual or entity.  In their written self-report, all excluded medical sources must include:  (1) the heading, “WRITTEN STATEMENT REGARDING SECTION 223(d)(5)(C) OF THE SOCIAL SECURITY ACT –  DO NOT REMOVE[,]” (2) their name and title, and (3) the applicable excluding event (i.e., felony conviction under sections 208 or 1632; section 1128 exclusion; or CMP, or assessment - or both - under section 1129 for submitting false evidence).  Felons must also include their date of conviction.  Those imposed with a CMP, assessment, or both, must provide the date(s) of imposition.  Sources excluded under section 1128 must include:  (1) the basis of their exclusion, (2) its effective date, and anticipated length, and (3) whether the Department of Health & Human Services’ Office of Inspector General (HHS’ OIG) waived it.  There is no form for this request.  Excluded medical sources create their own written statement, within the regulatory parameters, and submit it to SSA or State Disability Determination Services (DDS) employees.  They do not need information from someone else to create the written statement.  No one may remove an excluded medical source’s written report of exclusion.  SSA may also ask excluded medical sources to provide additional information or clarify already‑provided information.

    • 20 CFR 416.903b – This regulatory section requires sources excluded by section 223(d)(5)(C)(i) of the Act, as amended, to self-report their exclusion, in writing, each time they submit evidence related to a claim for initial or continuing benefits under Titles II or XVI of the Act.  This duty applies to evidence submitted to SSA directly, or through a representative, claimant, or other individual or entity.  In their written self-report, all excluded medical sources must include:  (1) the heading, “WRITTEN STATEMENT REGARDING SECTION 223(d)(5)(C) OF THE SOCIAL SECURITY     ACT – DO NOT REMOVE[,]” (2) their name and title, and (3) the applicable excluding event (i.e., felony conviction under sections 208 or 1632; section 1128 exclusion; or CMP or assessment - or both - under section 1129 for submitting false evidence).  Felons must also include their date of conviction.  Those imposed with a CMP, assessment, or both, must provide the date(s) of imposition.  Sources excluded under section 1128 must include:  (1) the basis of their exclusion, (2) its effective date, and anticipated length, and (3) whether the Department of Health & Human Services’ Office of Inspector General (HHS’ OIG) waived it.  There is no form for this request.  Statutorily excluded medical sources create their own written statement, within the regulatory parameters, and submit it to SSA or State agency (DDS) employees.  They do not need information from someone else to create the written statement.  No one may remove an excluded medical source’s written report of exclusion.  SSA may also ask excluded medical sources to provide additional information or clarify already‑provided information.

As respondents include the required exclusion in their regular electronic submission of medical evidence, SSA did not calculate any psychological costs.

The respondents for this collection are medical sources that:  (1) meet one of the exclusionary categories set forth in Section 223(d)(5)(C)(i) of the Act, as amended; (2) furnish evidence related to a claim for benefits under Titles II or XVI of the Act; and (3) had failed to self-identify as an excluded source of medical evidence as required in Section 223(d(5)(C)(i).

    3. Use of Information Technology to Collect the Information
Respondents must append a statement in compliance with regulations to the front of any medical evidence they submit.  As such, in information collections where respondents can submit their medical evidence electronically, they can also submit the statement required under 0960-0803 electronically attached to their electronically submitted medical evidence.  Because the statement is tied directly to the submitted medical evidence, we determined it is not appropriate to provide a separate mechanism for submitting this information collection.

In addition, we accept PDFs of medical evidence submitted through our Health IT or ERE portals, and, as mentioned above, we allow the respondents to submit the required statement through those means when submitting medical evidence. 

We also considered sending the Fact Sheet and follow-up notice to the medical sources via email, instead of mail.  However, we do not email these notices because we are unable to obtain accurate email addresses for the medical sources on a consistent basis, and the List of Excluded Individuals and Entities (LEIE) database does not provide email addresses.  Since we are unable to obtain accurate email addresses for the medical sources on a consistent basis, we determined that it is most appropriate to mail these notices.  If we are consistently able to obtain accurate email addresses in the future, we will change this policy. 

Given that we have no specific form for this information collection, and respondents create their own statements to submit to us when they submit medical evidence (which they can submit electronically with the evidence), we do not have plans to create an Internet, web-based application or submission form for this information collection. 

    4. Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it precludes duplication.  SSA does not use another collection instrument to obtain similar data.


    5. Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities. 

    6. Consequence of Not Collecting Information or Collecting it Less Frequently
If medical sources excluded under section 223(d)(5)(C)(i) of the Act, as amended, do not provide the information requested in 20 CFR 404.1503b and 416.903b, they will not meet their regulatory requirement to self-report their excluded status in writing each time they submit evidence related to a claim for benefits under Titles II or XVI of the Act.  Because we have no other way to collect the information, we cannot collect it less frequently.  There are no technical or legal obstacles to burden reduction. 

    7. Special Circumstances 
Because we have no other way to collect the information, we require medical sources excluded under section 223(d)(5)(C)(i) of the Act, as amended, to self-report their excluded status, in writing, each time they submit evidence related to a claim for initial or continuing benefits under Titles II or XVI of the Act.  As such, we may require affected medical sources to self-report their excluded status more often than on a quarterly basis.  We may also require these affected medical sources to prepare a written response to this information collection in fewer than 30 days after receipt of it.

    8. Solicitation of Public Comment and Other Consultations with the Public 
The 60-day advance Federal Register Notice published on May 26, 2026, at 91 FR 30774, and we received no public comments.  The 30-day FRN published on July 31, 2026, at 91 FR 48475.  If we receive any comments in response to this Notice, we will forward them to OMB.  We did not consult with the public in the development revision of this form.

    9. Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents. 

    10. Assurances of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

    11. Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.

    12. Estimates of Public Reporting Burden
Please see the burden chart below:

Method
of Completion
Number 
of Respondents
Frequency
of 
Response
Number of Responses
Average Burden Per Response (minutes)
Estimated Total Annual Burden (hours) 
Average Theoretical Cost Amount (dollars)*
Total Annual Opportunity Cost (dollars) **
404.1503b(c) (Fact Sheet)

2,670

1
2,670

20

890
 $52.26 *
$46,511**
416.903b(c)
(Follow-up Notice)
10

4
40
20
13
$52.26*
$679**
Totals
2,680

2,710
20
903

$47,190**
* We based this figure on the average Healthcare Practitioners and Technical Occupations worker’s hourly wages, as reported by Bureau of Labor Statistics data (Occupational Employment and Wage Statistics).

** This figure does not represent actual costs that SSA is imposing on individuals; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the information collection.  There is no actual charge to respondents to complete the information collection.

As the medical sources append the documentation to the evidence which they submit either via mail or electronically (via ERE or Health IT modalities), we do not estimate any average wait time or travel time for submitting this information.  

We did not include a separate Learning Cost for this information collection, as we include the Learning Cost in the burdens listed in the chart above.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection.  Per our management information data, we believe that 20 minutes accurately shows the average burden per response for learning about the program; receiving notices as needed; reading and understanding instructions; gathering the data and documents needed; answering the questions and completing the information collection instrument.  Based on our current management information data, the current burden information we provided is accurate.  The total burden for this ICR is 903 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $47,190.  SSA does not charge respondents to complete our applications.

NOTE:  This ICR covers the burden for the exclusion statement-related documents only (Fact Sheet and follow-up notice).  We cover the burden for uploading medical evidence under separate ICRs, namely OMB No. 0960-0555 (Clearance of Information Collections Conducted by State Disability Determination Services on Behalf of SSA), and OMB No. 0960-0798 (Social Security Administration Health IT Partner Program Assessment – Participating Facilities and Available Content Form).

13. 	Annual Cost to the Respondents (Other) 
This collection does not impose a known cost burden on the respondents.   


    14. Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $96,116.  This estimate accounts for costs from the following areas:

Description of Cost Factor
Methodology for Estimating Cost
Cost in Dollars*
Designing and Printing the Form
Design Cost + Printing Cost
$1,740
Distribution, Shipping, and Material Costs for the Form
Distribution + Shipping + Material Cost
$2,385
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time
GS-9 employee x # of responses x processing time
$90,785
Full-Time Equivalent Costs
Out of pocket costs + Other expenses for providing this service
$0*
Systems Development, Updating, and Maintenance
GS-9 employee x man hours for development, updating, maintenance
$1,206
Quantifiable IT Costs
Any additional IT costs
$0*
Total

$96,116
* We have inserted a $0 amount for cost factors that do not apply to this collection.
SSA is unable to break down the costs to the Federal government further than we already have.  Because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15.	Program Changes or Adjustments to the Information Collection Request
When we cleared the this ICR in 2023, the burden was 200 hours.  However, we are currently reporting a burden of 903 hours.  This change stems from both an increase in individuals reported to us who are initially identified as excluded sources of evidence – currently estimated at 2,670 (to whom we send the Fact Sheet informing them of their excluded status and our rules regarding the required statement), but also an overall decrease in the number of respondents who submit medical evidence without the required statement – currently estimated at 40 (to whom we send the follow-up notice).  This demonstrates that there are fewer individuals who are either unfamiliar with our rules regarding the statement or who do not comply with our rules upon learning of them.   

Although the overall number of individuals identified as excluded sources has increased (which largely accounts for the increased annual cost to the Federal government due to the need to initially send the Fact Sheets), SSA continues to observe fewer excluded sources who submit evidence to us either without the required statement, or who submit evidence at all, as the years progress.  These figures represent current Management Information data.

16.  	Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.

17.	Displaying the OMB Approval Expiration Date
SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

    18. Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B.     	Collections of Information Employing Statistical Methods

	SSA does not use statistical methods for this information collection.