SSA-186 Temporary Institutionalization Statement to Maintain Hou

Form SSA-186 (XX-XXXX)
Social Security Administration

Page 1 of 2
OMB No. 0960-0516

Temporary Institutionalization Statement to Maintain
Household and Physician Certification
The Social Security Administration (SSA) can provide temporary institutionalization benefits to a recipient if:
• The recipient is in a medical facility or plans to enter a medical facility;
• The stay is likely not to exceed 90 days; and
• The recipient needs Supplemental Security Income benefits to maintain his or her home or living arrangement while in
the medical facility.
WHO SHOULD COMPLETE THIS FORM
There are two parts that need to be completed on this form:
1. The recipient or the recipient's representative payee may complete and sign page 1 of the form.
2. The physician who is providing the medical treatment must complete and sign page 2 of the form.
NOTE: If the recipient does not have a representative payee and the recipient is incapacitated, a knowledgeable source
can sign page 1 and submit the form on the recipient’s behalf to SSA.
NEXT STEPS
• If you are the recipient, the recipient's representative payee, or a knowledgeable source (if applicable):
○ Contact the local SSA FO to notify us that the recipient has or will be entering a medical facility for 90
consecutive days or less;
○ Complete and sign the Patient/Recipient Statement below that the recipient needs to maintain his or her
household or living arrangement while in the medical facility; and
○ Present the form to the recipient's physician to complete.
• If you are the physician, complete and sign the Physician Statement below. Upon completion, return the form to the
person who submitted it (Patient/recipient, recipient’s representative payee, or a knowledgeable source acting on
behalf of the recipient).
• Submit the form to SSA via mail, fax, or to the recipient’s local SSA FO before the discharge date or by the 90th day
from admission, whichever is earlier.
Visit www.ssa.gov/locator/ to find the recipient’s local SSA FO address, phone number, and fax number.
Patient/Recipient Name:

Patient/Recipient SSN

Medical Facility Name and Address:

PATIENT/RECIPIENT STATEMENT:

needs to continue to
(Patient/Recipient Name)
receive his or her Supplemental Security Income payment to continue to maintain his or her household or living arrangement that
he or she intends to return to after release from the medical facility.
Patient/Recipient/Representative Payee:
Name:

Signature

Date

NOTE: If the recipient does not have a representative payee and the recipient is incapacitated, a knowledgeable source can sign
and submit the form on the recipient’s behalf to SSA.

Form SSA-186 (XX-XXXX)

Page 2 of 2

PHYSICIAN STATEMENT:
Physician Name:

Please complete the more accurate statement (do not complete both statements):

(Patient/Recipient Name)
is expected to be in this medical facility for 90 or fewer days.

(Patient/Recipient Name)
is expected to be in this medical facility for more than 90 days

Physician Signature

Date

Privacy Act Statement
Collection and Use of Personal Information
Section 1611(e)(1) of the Social Security Act, as amended, allows us to collect this information. Furnishing
us this information is voluntary. However, failing to provide all or part of the information may result in a
reduction in Supplemental Security Income (SSI) benefits.
We will use the information you provide to make a determination regarding Temporary Institutionalization
benefits. We may also share the information for the following purposes, called routine uses:
• To State agencies to enable them to assist in the effect and efficient administration of the
Supplemental Security Income program; and
• To State agencies to enable those agencies which have elected Federal administration of their
supplementation programs to monitor changes in applicant/recipient income, special needs, and
circumstances.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws.
For example, where authorized, we may use and disclose this information in computer matching programs,
in which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0103,
entitled Supplemental Security Income Record and Special Veterans Benefits, as published in the Federal
Register (FR) on January 11, 2006, at 71 FR 1830. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.
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 (OMB) control number. We estimate
that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments regarding this burden estimate or any other aspect of this collection, including suggestions
for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.