Form SSA-787 Physician's/Medical Officer's Statement of Patient's Cap

Fonn Approved
OMB No.0960-0024

TOE 250

SOCIAL SECURITY ADMINISTRATION

PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT OF PATIENT'S CAPABILITY TO MANAGE BENEFITS
Paperwork Reduction Act Statement - This Information collection meets the requirements of 44 U. In replying, use this address:
S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to SOCIAL SECURITY ADMINISTRATION
answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and
answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. To find the nearest office, call 1-800-772-1213 (TTY 1.800-325-0778). Send only
comments on our time estimate above to: SSA, 6401 Security Blvd. Baltimore, MD 21235-6401.

See Revised PRA Attached

See Revised Privacy Act Statement Attached

TELEPHONE NUMBER (Including Area Code)

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DATE

Privacy Act Statement

Sections 205(a) and 205(i), ofthe Social Security Act, as amended, authorizes us to collect this SSA CONTACT
information. ilie information is needed to make a determination regarding whether or not the
named individual should be paid benefits directlY or whether benefits snould be paid to a
representative payee. The information you fumisli on this form is voluntary. However, failure
to provide all or part of the information could prevent an accurate and timely decision on the
proper payee for benefit receipt purposes.
IDENTIFYING INFORMATION (SSA Only)

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We rarely use the information you supply for any pUrPose other than for making a If different from patient
determination on a claim. However\ we may use it for the administration and integri~ of Social
Security programs. We may' also disclose Information to another person or to anottier agency
in accordance with approvea routine uses, which include but are not limited to: (1) to enable a
third tPtarty or an agency to assist Social Security in establishing rights to Social Secu!'itY
bene ts andlor coverage; (2) to comply with Federal laws requiril'!9 the release of information I-NA-M-E-O-F-W-A-G-E-E-A-R-N-E-R-O-R-S-E-L-F--­
from Social Securil)' records (e.g. to ilie Government Accountability Office and Department of
Veteran Affairs); (3) to make determinations for eligibility in Similar health and income EMPLOYED PERSON
maintenance programs at the Federal, State, and local level; and (4) to facilitate statistical
research, audlt or investigative activities necessary to assure the integrity of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local govemmenl
agencies. Information from these matching prFile Typeapplication/pdfFile Modified2009-12-28File Created2009-12-03