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

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No.0960-0024

TOE 250

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.S. In replying, use this address:
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 Statement Attached

TELEPHONE NUMBER (Including Area Code)

(
Privacy Act Statement

See Revised Privacy Act Statement Attached

)

-

DATE

Sections 205(a) and 205(j), of the Social Security Act, as amended, authorizes us to collect this
information. The information is needed to make a determination regarding whether or not the SSA CONTACT
named individual should be paid benefits directly or whether benefits should be paid to a
representative payee. The information you furnish 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)
If different from patient

We rarely use the information you supply for any purpose other than for making a
determination on a claim. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another agency
in accordance with approved routine uses, which include but are not limited to: (1) to enable a
third party or an agency to assist Social Security in establishing rights to Social Security
benefits and/or coverage; (2) to comply with Federal laws requiring the release of information
from Social Security records (e.g., to the Government Accountability Office and Department of NAME OF WAGE EARNER OR SELFVeteran 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, audit 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 government
agencies. Information from these matching programs can be used to establish or verify a
person's eligibility for Federally funded and administered benefit programs and for repayment
of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record Notices SOCIAL SECURITY NUMBER
60-0089 and 60-0222. The notices, additional information regarding this form, and information
regarding our programs and systems, are available on-line at www.ssa.gov or at your local
Social Security office.

PATIENT'S NAME

-

PATIENT'S ADDRESS (Number and Street, City, State, and ZIP Code)

PATIENT'S SOCIAL SECURITY NUMBER

-

-

PATIENT'S DATE OF
BIRTH

YOUR HELP IS NEEDED
The patient shown above has filed for or is receiving Social Security or Supplemental Security Income payments. We need
you to complete the back of this form and return it to us in the enclosed envelope to help us decide if we should pay this
person directly or if he or she needs a representative payee to handle the funds. Please Note: This determination affects
how benefits are paid and has no bearing on disability determinations; SSA will NOT pay for this information. Thank you for
your help.
WHO IS A REPRESENTATIVE PAYEE
A representative payee is someone who manages the patient's money to make sure the patient's needs are met. The
payee has a strong and continuing interest in the patient's well-being and is usually a family member or close friend.
WHO NEEDS A REPRESENTATIVE PAYEE
Some individuals age 18 and older who have mental or physical impairments are not capable of handling their funds or
directing others how to handle them to meet their basic needs, so we select a representative payee to receive their
payments. Examples of impairments which may cause incapability are senility, severe brain damage or chronic
schizophrenia. However, even though a person may need some assistance with such things as bill paying, etc., does not
necessarily mean he/she cannot make decisions concerning basic needs and is incapable of managing his/her own money.

PLEASE COMPLETE THE INFORMATION ON THE REVERSE OF THIS FORM
Form SSA-787 (02-2009) ef (02-2009) Destroy Prior Editions

1. Date you last examined the patient
2. Do you believe the patient is capable of managing or directing the management of benefits in his or her own best interest?
By capable we mean that the patient:
•

Is able to understand and act on the ordinary affairs of life, such as providing for own adequate food, housing,
clothing, etc., and

• Is able, in spite of physical impairments, to manage funds or direct others how to manage them.
No

Yes
If "Yes", please omit
question 3, but be sure to
sign and date the form.

Unsure
If "unsure",
please explain.

If "No", please provide a brief summary
of the findings that led to this conclusion.
Also, complete question 3.

3. Do you expect the patient to be able to manage funds in the future (for example, the patient is temporarily unconscious)?
Yes

No

If yes, please explain.

NAME OF PHYSICIAN/MEDICAL OFFICER (Please print.)

ADDRESS (Number and street, City, State, and ZIP Code)

TITLE

TELEPHONE NUMBER (Include Area Code)

(

)

-

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or
misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
sent to prison, or may face other penalties, or both.
DATE
SIGNATURE OF PHYSICIAN/
MEDICAL OFFICER
Form SSA-787 (02-2009) ef (02-2009)

SSA will insert the following revised Privacy Act and PRA Statements into the
form at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 205(j) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to make a determination regarding whether
or not the named individual should be paid benefits directly or whether benefits should be paid to
a representative payee.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent an accurate and timely decision on the proper payee for benefit receipt
purposes.
We rarely use this information for any purpose other than determining benefits. However, we
may also disclose information to another person or to another agency in accordance with
approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of
Census and to private entities under contract with us).
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 government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for federally-funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
A complete list of routine uses of the information you gave us is available in our Privacy Act
Systems of Records Notices entitled, Claims Folder System, 60-0089 and Master Representative
Payee File, 60-0222. Additional information about these and other systems of records notices
and our programs are available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to 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 OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.
0001. Send only comments relating to our time
estimate to this address, not the completed form.