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
A. Justification
Introduction/Authoring Laws and Regulations
If it is not in the best interest of a beneficiary to directly receive Social Security benefits, a relative or other person may act as a representative payee for this beneficiary, as established by Sections 205(j) and 1631(a)(2) of the Social Security Act (the Act). These sections specifically state that if the Commissioner of the Social Security Administration (SSA) deems it appropriate, SSA may issue benefits to any other person (public or private agency) who is interested in, or concerned with, the welfare of the beneficiary. Sections 20 CFR 404.2015 and 416.615 of the Code of Federal Regulations describe the factors used in determining whether to appoint a representative payee. Section 205(a) of the Act gives the Commissioner full power and authority to make rules and regulations, to establish procedures, and to adopt reasonable and proper rules for the nature and extent of the evidence as well as the methods of taking and furnishing the same in order to establish the right to benefits.
Description of Collection
SSA must obtain evidence from the beneficiary’s physician before determining whether a beneficiary needs a representative payee. Therefore, SSA asks the physician or other medical officer to complete form SSA-787 to provide SSA with this information. SSA uses the information collected by this form to: a) determine the individual’s capability or lack thereof to handle his/her own benefits and b) select a representative payee, if needed. The respondents are physicians of the beneficiaries or medical officers of the institution in which the beneficiaries reside.
Use of Information Technology to Collect the Information
SSA has not made Form SSA-787 available electronically. This form is an SSA-initiated form which we send to physicians, medical officers or treating sources with specific pre-filled information about the beneficiary (i.e., SSN, name and address). Since SSA does not currently possess the technology to send pre-filled electronic application to respondents via an Internet, we cannot make this form available electronically. However, a PDF file does exist for internal access by SSA personnel, and we accept faxed responses from the respondents.
Why We Cannot Use Duplicate Information
The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to collect similar data.
Minimizing Burden on Small Respondents
This information collection may involve doctors working in small clinics but will not significantly affect a substantial number of other small businesses or other small entities. We minimize the burden by sending the form with pre-filled information.
Consequence of Not Collecting Information or Collecting it Less Frequently
SSA requires the collection of this information due to the agency’s need to determine whether an individual can handle his or her own benefits. SSA cannot pay benefits until the beneficiary’s competence is established and if necessary, a representative payee is appointed. Therefore, SSA cannot collect this information less frequently. There are no technical or legal obstacles to prevent burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on October 26, 2009, at 74 FR 55080, and SSA received no public comments. The second Notice published on January 22, 2010, at 75 FR 3778. If we receive any comments in response to the 30-day Notice, we will forward them to OMB. SSA did not consult members of the public in the development of this form.
Payment or Gifts to Respondents
SSA provides no payment or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information it is requesting 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.
Justification for Sensitive Questions
The information collection contains some questions that may lead to the disclosure of sensitive information since the beneficiary's medical history may be included in the collection. However, this information is necessary to determine if a beneficiary can receive benefits directly.
Estimates of Public Reporting Burden
Approximately 120,000 respondents use this form. The estimated completion time is 10 minutes. Thus, the total burden is 20,000 hours. The total burden represents burden hours, and SSA did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
There is no known cost burden to the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $184,800. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
Program Changes or Adjustments to the Information Collection Request
There are no changes in the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
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 is not using statistical methods for this collection.
| File Type | application/msword |
| Author | 152290 |
| Last Modified By | 666429 |
| File Modified | 2010-01-28 |
| File Created | 2009-10-27 |