Supporting Statement for Request for Evidence from Doctor (HA-66) and Evidence from Hospital (HA-67)
20 CFR 404 Subpart P and 20 CFR 416 Subpart I
OMB No. 0960-0722
A. Justification
Introduction/Authoring Laws and Regulations
Section 702(a)(5) of the Social Security Act (Act) allows the Commissioner of the Social Security Administration (SSA) to prescribe such rules and regulations as the Commissioner determines necessary to administer the Social Security programs, under Title II of the Act, and the Supplemental Security Income program, under Title XVI of the Act. Sections 205(a) and 1631(d) of the Act require the Commissioner to regulate the method of taking and furnishing evidence to establish the rights to benefits under Titles II and XVI. A claimant for benefits based on disability is responsible for furnishing medical evidence of disability as set forth in Sections 223(d)(5) and 1614(a)(3)(H)(i) of the Act. These sections also require the Commissioner to develop a complete medical history of at least the twelve months preceding the month of the application for benefits in any case in which SSA determined the individual is not disabled.
The Commissioner published regulations on determining disability and blindness, as set forth at 20 CFR 404 Subpart P and 20 CFR 416 Subpart I of the Code of Federal Regulations. Sections 404.1512 and 416.912 describe the responsibilities of the claimant to submit evidence of disability and of the Commissioner to develop a complete medical history before determining a claimant is not disabled. Sections 404.1513(a) and 416.913(a) describe acceptable sources of medical and other evidence necessary to establish impairment. Sections 404.1513(b) and 416.913(b) describe the type of information necessary to establish the existence and extent of a medically determinable impairment. Sections 404.1513(e) and 416.913(e) require SSA to create complete and detailed evidence in the case file, including the evidence from medical sources, to allow us to determine, among other things, the individual’s residual functional capacity to do work-related activities. Sections 404.1514 and 416.914 explain how SSA will pay medical sources the reasonable cost of providing us any existing medical evidence we need and request.
Description of Collection
SSA uses Forms HA-66 and HA-67 to request medical evidence from medical and other sources identified by the claimants as having information relative to their impairments or ability to do work-related activities. In addition to accepting manual paper responses, SSA sends a barcode with the HA-66 and HA-67 allowing respondents to fax the information directly into the electronic claims folder rather than submitting it manually. While we always send page 3 of these forms, the Medical Source Information Request, we allow respondents to furnish the information on a separate invoice or their own stationary. If we do not receive this information, we cannot pay the medical sources for the information. Approximately two percent of all respondents do not submit this information. Respondents are doctors and hospitals who evaluated the claimant.
Use of Information Technology to Collect the Information
SSA’s Electronic Records Express (ERE) website, approved under OMB Number 0960-0753, permits and encourages direct electronic submission of medical records, and offers major advantages in speed, efficiency, and tracking of information, particularly for medical providers using health information technology. Approximately 75% of the medical sources respond electronically through ERE.
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 obtain similar data.
Minimizing Burden on Small Respondents
In accordance with sections 223(d)(5)(A) and 1614(a)(3)(H) of the Act, we compensate the respondents for providing medical reports. In addition, the ALJs only collect the information they require to make a disability determination for the claimant. As such, we minimized the effect on small entities to the extent possible.
Consequence of Not Collecting Information or Collecting it Less Frequently
SSA requires the information to ensure the ALJ obtains all pertinent medical information before reaching a disability decision within the meaning of the Act. If we did not collect this information, disabled individuals might not receive the benefits for which they are eligible. Since we only collect this information on as needed bases, we cannot collect it less frequently. There are no technical or legal obstacles that 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 March 3, 2014, at 79 FR 11852, and we received no public comments. SSA published the second Notice on May 23, 2014, at 79 FR 29834. If we receive comments in response to the 30-day Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.
Payment or Gifts to Respondents
To compensate doctors and hospitals that provide medical reports, we require entities to complete the included Medical Source Information Request on Page 3 of the HA‑66 or HA-67, or submit the same information on a separate invoice, indicating the amount they charge for providing the report.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects 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 does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
We estimate 12,000 respondents will provide an average of 22 reports annually for each of these forms, with an average burden per response of 15 minutes, for an annual total burden of 50,000 hours each. We base our estimates on current hearing workloads and SSA’s current management information on requests for medical evidence of record.
Form Type |
Number of Respondents |
Frequency of Response |
Number of Responses |
Average Burden per Response (minutes) |
Estimated Annual Burden (hours) |
HA-66 – Paper Version |
3,060 |
22 |
67,320
|
15 |
16,830 |
HA-66 – Electronic Version (ERE or barcode)
|
8,940 |
22 |
196,680 |
15 |
49,170 |
HA-67 – Paper Version |
3,060 |
22 |
67,320 |
15 |
16,830 |
HA-67 – Electronic Version (ERE or barcode) |
8,940 |
22 |
196,680 |
15 |
49,170 |
Totals |
24,000 |
|
528,000 |
|
132,000 |
The estimated annual burden for this collection is 132,000 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $1,232,000. This estimate is a projection of the costs for printing and distributing the collection instrument, collecting the information, and for compensating the medical sources for the information.
The cost of maintaining the electronic systems (ERE and the bar code scanner) is negligible. Because the cost of maintaining the system which collects this information is accounted for within the cost of maintaining all of SSA’s automated systems, it is not possible to calculate the cost associated with just one Internet application.
Program Changes or Adjustments to the Information Collection Request
There are no changes to 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.
SSA is not requesting an exception to the requirement to display the OMB approval expiration date for the ERE collection; however, we discuss ERE within its own information collection request under OMB Control Number 0960-0753.
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. Collection of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Request for Evidence from Doctor |
| Author | 751550 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |