Form SSA-787 Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits

What Is Form SSA-787?

Form SSA-787, Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits - also known as SSA Form 787 - is a form used to determine if a person is able to manage funds or they need a representative payee. This form contains information about the patient who receives Social Security benefits or Supplemental Security Income (SSI) payments. A medical officer or the patient's physician should fill out the reverse of the form. This form is part of the Representative Payee program paperwork.

What Is the Most Recent Form SSA-787?

The most recent version of the SSA Form 787 was issued by the Social Security Administration (SSA) in November 2015 with all prior editions being obsolete and destroyed. Since this form is only mailed to the medical officers or physicians, this form is unavailable for digital filing. An SSA-787 printable form is available below for reference.

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Form Approved
Social Security Administration
OMB No. 0960-0024
PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT OF
PATIENT'S CAPABILITY TO MANAGE BENEFITS
In replying, use this address:
TELEPHONE NUMBER (Including Area Code)
SOCIAL SECURITY ADMINISTRATION
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)
Page 1
Destroy Prior Editions
Form Approved
Social Security Administration
OMB No. 0960-0024
PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT OF
PATIENT'S CAPABILITY TO MANAGE BENEFITS
In replying, use this address:
TELEPHONE NUMBER (Including Area Code)
SOCIAL SECURITY ADMINISTRATION
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)
Page 1
Destroy Prior Editions
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
Unsure
If "Yes", please omit
If "No", please provide a brief summary
If "Unsure",
question 3, but be
of the findings that led to this conclusion.
please explain.
sure to sign and date
Also, complete question 3.
the form.
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
DATE
Form SSA-787 (11-2015) UF (11-2015)
Page 2
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)
Page 3

Download Form SSA-787 Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits

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SSA-787 Form Instructions

A representative payee is a person who receives benefits for the beneficiary and manages them for their well-being. If the beneficiary is unable to manage funds and has difficulties making decisions regarding their health due to their condition or minor age, a representative payee is necessary. Usually, this person is a family member or a close friend. A representative payee can be assigned by the SSA or they can file Form SSA-11-BK, Request to Be Selected as Payee. Alternatively, the SSA can assign a qualified organization as a representative payee.

A representative payee cannot make decisions regarding the beneficiary's treatment or placement. They cannot sign legal documents for the beneficiary, use the benefit funds for their personal expenses, transfer the funds to their personal bank account, or manage the funds after they stop being a payee. However, they are allowed to reimburse themselves if they made reasonable expenses for the beneficiary from their own funds.

A representative payee receives the funds, but officially the funds belong to the beneficiary and can be used only for their needs. The payee has to keep a record of their expenses to provide it to the SSA upon request. If the funds are misused, the beneficiary should notify the SSA. The administration stops the payments and initiates an investigation. If the payee is unable to perform their responsibilities, the SSA will assign another person or organization. The payee also cannot charge the beneficiary, except in cases when a payee is an organization authorized by the SSA.

If a beneficiary wants to stop the representative payments, they should file a request for a direct payment and provide the supporting documentation. The SSA will make a decision based on the information provided by the beneficiary and their physician who will receive Form SSA-787.

How to Fill out SSA-787 Form?

Instructions for Form SSA-787 are as follows:

  1. Block 1. Enter the date of your last examination of the patient whose name is printed on the form;
  2. Block 2. Mark the applicable box, indicating whether you believe the patient is able to manage their benefits in their own best interests. Negative and Unsure answers require further explanation. You have to evaluate the patient's ability to understand and perform everyday activities, providing themselves with food, clothing, housing. You also have to check their ability to manage funds or direct others on how to use them;
  3. Block 3. Indicate, whether you believe the patient will be able to manage the benefits in the future. A positive answer requires an explanation. This block is applicable if the previous block contained a negative or unsure answer;
  4. Enter your name, title, address and phone number before signing and dating the form. Mail the completed form to the address provided on the form.
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