Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)

Clearance of Information Collections Conducted by State Disability Determination Services on Behalf of SSA

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0555 can be found here:

Documents and Forms

Document Name Document Type
0960-0555 sample CE forms.pdf Other-Sample of state DDS Claimant R

Information Collection (IC) Details

IC Title:	Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1503a 20 CFR 404.1513 20 CFR 404.1514 20 CFR 404.1512 20 CFR 404.1517 20 CFR 404.1519 20 CFR 416.1024 20 CFR 404.1613 20 CFR 404.1614 20 CFR 404.1624 20 CFR 416.903a 20 CFR 416.912 20 CFR 416.913 20 CFR 416.914 20 CFR 416.917 20 CFR 416.919 20 CFR 416.1013 20 CFR 416.1014

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Sample of state DDS Claimant Report Letter/Form			0960-0555 sample CE forms.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,500,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500,000	1,500,000
Annual IC Time Burden (Hours)	125,000	125,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.