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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0024 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-787 Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits Form
SSA-787 Physician's/Medical Officer's Statement of Patient's Cap SSA-787 - Revised Version.pdf Form
SSA-787 - Current Version.pdf Current SSA-787 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.615 20 CFR 404.2015

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-787	Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits	SSA-787 - Revised Version.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	120,000	120,000
Annual IC Time Burden (Hours)	20,000	20,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-787	SSA-787 - Current Version.pdf	10/19/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.