Treating Physician Consultative Examination Interest Form

Forms and Documents

Document Name	Status
Form SSA-84 Treating Physician Consultative Examination Interest Form Form	New
SSA-91--AUTHORIZATION TO RELEASE MEDICAL REPORT TO PHYSICIAN FORM.doc Supplementary Document	2007-06-21
Cover Letter--Child Medical Report.doc Supplementary Document	2007-06-21
Cover Letter--Adult Medical Report.doc Supplementary Document	2007-06-21
Addendum--SSA-84.doc Supplementary Document	2007-04-12
Supporting Statement--SSA-84.doc Supporting Statement A	2007-06-21

IC Document Collections

IC ID	Document Title	Status
179601	Treating Physician Consultative Examination Interest Form Form	New

ICR Details

OMB Control No: 0960-0751	ICR Reference No: 200704-0960-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Treating Physician Consultative Examination Interest Form
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/14/2007
	Date Received in OIRA: 06/21/2007
Terms of Clearance: This ICR is approved on the understanding that respondents do not have to supply the same information twice (once to state agencies and then again to SSA OMVE), even though the supporting statement says that states and SSA collect the same information. Rather, at the point in time that this information is being collected, it is either collected by the state DDS (because they are processing the case) or it is collected by OMVE (because we are processing the case), not by both.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2010	36 Months From Approved
Responses	168	0	0
Time Burden (Hours)	14	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The individual's treating physician (TP) is the preferred source to perform a consultative examination (CE). SSA uses the SSA-84 to ascertain whether the TP is interested in performing the CE. This form is sent to the claimant's treating physician along with the medical evidence of record request letter. If the treating physician is interested in performing the CE, he or she indicates interest by completing the SSA-84 and returning it to SSA. If the form is not returned, SSA assumes that the TP is not interested in performing the CE. Respondents are the claimants’ treating physicians.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 7107	02/14/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 26443	05/09/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Treating Physician Consultative Examination Interest Form	SSA-84	Treating Physician Consultative Examination Interest Form

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ICR Summary of Burden

	Total Approved	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	168	0	0	168	0	0
Annual Time Burden (Hours)	14	0	0	14	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is an information collection in use without an OMB control number that will increase the public reporting burden.

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Annual Cost to Federal Government: $259

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/21/2007

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