Medical Source Opinion of Patient's Capability to Manage Benefits

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205, 807, and 1631(a) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from making a determination regarding the beneficiary’s
capability or inability to handle his or her own benefits.
We will use the information to determine the beneficiary’s need for a representative payee. We
may also share your information for the following purposes, called routine uses:
•

To Federal, State, or local agencies for administering cash or non-cash income
maintenance or health maintenance programs; and

•

To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its programs.

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 Notices
(SORN) 60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0222, entitled Master Representative Payee File, as
published in the FR on April 22, 2013, at 78 FR 23811. Additional information, and a full listing
of all our SORNs, is available on our website at www.ssa.gov/privacy.