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

Form Approved
OMB No. 0960-0024

Social Security Administration

PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT OF
PATIENT'S CAPABILITY TO MANAGE BENEFITS
In replying, use this address:
SOCIAL SECURITY ADMINISTRATION

TELEPHONE NUMBER (Including Area Code)

DATE

SSA CONTACT
IDENTIFYING INFORMATION (SSA Only)
If different from patient

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

PATIENT'S NAME
PATIENT'S SOCIAL SECURITY NUMBER

PATIENT'S DATE OF BIRTH

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

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 (11-2015) UF (11-2015)
Destroy Prior Editions

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PATIENT'S NAME
PATIENT'S SOCIAL SECURITY NUMBER

PATIENT'S DATE OF BIRTH

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

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 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.
Yes

No

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

Unsure

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

If "Unsure",
please explain.

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.)

TITLE

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

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 statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.
SIGNATURE OF PHYSICIAN/MEDICAL OFFICER

Form SSA-787 (11-2015) UF (11-2015)

DATE

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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 the beneficiary's need for a
representative payee.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination regarding
management of benefits. However, we may use the information for the administration of our programs
including sharing information:
1. To comply with Federal laws requiring the release of information form our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity
and improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
A list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records Notices 60-0089, entitled Claims Folders Systems; and, 60-0222, entitled Master
Representative Payee File. Additional information about these and other system of records notices and our
programs is available online at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in our 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.
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
1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to
this address, not the completed form.

Form SSA-787 (11-2015) UF (11-2015)

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