0960-0102 - Addendum to the Supporting Statement

OMB No. 0960-0102 (FORM SSA-3827)

MEDICAL REPORT (INDIVIDUAL WITH CHILDHOOD IMPAIRMENT)

ADDENDUM TO THE SUPPORTING STATEMENT

Revisions to the Collection Instrument

Below are several minor revisions which we will make at the next scheduled reprinting of this form.

PRIVACY ACT STATEMENT

• “Section 223(d) of the Social Security Act” has been changed to “Section 223(d)(5)(A)”. The latter reference is a more complete citation which we display on other, similar forms.

• The citation “Section 1631(e)(1)” has been changed to “Section 1631(d)(1), which is the correct citation.

NAME AND IDENTIFYING INFORMATION ABOUT THE MEDICAL SOURCE WHO COMPLETED THE FORM

• In the box requesting the name and address of the medical source who completed the form, we changed “PHYSICIAN’S NAME” to “MEDICAL SOURCE’S NAME.’’ This change reflects the fact that form SSA-3827 is completed by medical professionals other than physicians, such as physician’s assistants, nurse practitioners, physical therapists, and hospital medical records librarians.

Addendum to the Supporting Statement

0960-0102 (SSA-3827)

2/5/2021