Addendum to Supporting Statement 0960-0024

Addendum to the Supporting Statement for Form SSA-787

Physician’s/Medical Officer’s Statement of Patient’s Capability to Manage Benefits

20 CFR 404.2015 and 416.615

OMB No. 0960-0024

Revision to the Collection Instrument

SSA is revising the SSA-787 to add the patient’s Name, SSN, DOB, and Address to page 2 of the form.

Currently, SSA mails this document to the physicians or treating sources to obtain medical evidence to aid in determining a beneficiary’s capability to manage benefits. Improvements in communication techniques have created new ways of returning these documents. Physicians and/or treating sources are now returning the form SSA-787 by fax; however some are only returning the back page or page 2 to SSA with their determinations. The current back page does not contain any identifying information about the beneficiary (i.e., name, SSN, date of birth or address). By adding this information it will aid in FO, TSC and PSC associating the document with the correct file and expedite processing of the capability decision. In addition, it will avoid follow up contacts for information already prepared.

We will continue to use the old stock until we run out of copies after which we will switch to the new version.

Justification for Resubmitting the ICR Within One Year of Approval

SSA is resubmitting this ICR with the above revisions now because we are finding that many physicians and treating sources are returning only page 2 (their determinations) by fax or mail. The field office personnel cannot associate the one page with the paper or electronic file and, subsequently, have to recontact the physicians and treating sources to determine where these pages should be filed. This problem creates further delay in our capability decisions. Had we realized this problem prior to the initial submission of the ICR in 2009, we would have corrected it then. Therefore, we are correcting it now.