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Get SSA-787 2018-2024

PLEASE COMPLETE THE INFORMATION ON THE REVERSE OF THIS FORM Form SSA-787 05-2010 ef 05-2010 Destroy Prior Editions 1. 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. In replying use this address S*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 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 1-800-772-1213 TTY 1-800-325-0778. Send only comments relating to our time estimate above to SSA 6401 Security Blvd Baltimore MD 21235-6401. TELEPHONE NUMBER Including Area Code - DATE Privacy Act Statement SSA CONTACT Sections 205 a and 205 j of the Social Security Act as amended authorize us to collect this information* The information is needed 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. 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 IDENTIFYING INFORMATION SSA Only If different from patient proper payee for benefit receipt purposes. 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 NAME OF WAGE EARNER OR SELFbenefits and/or coverage 2 to comply with Federal laws requiring the release of information EMPLOYED PERSON from Social Security records e*g* to the Government Accountability Office and Department of Veteran 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 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.

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