Request for Evidence from Doctor or Hospital

Forms and Documents

Document Name	Status
Form HA-66 HA-66 with Medical Source Information - paper submission Form and Instruction	Modified
Form HA-67 HA-67 with Medical Source Information - paper submission Form and Instruction	Modified
Supporting Statement - 0722.docx Supporting Statement A	2014-05-26

IC Document Collections

IC ID	Document Title	Status
9779	HA-66 with Medical Source Information - paper submission Form and Instruction	Modified
195762	HA-67 with Medical Source Information - electronic submission Other-Internet Screen	Modified
195760	HA-67 with Medical Source Information - paper submission Form and Instruction	Modified
195758	HA-66 with Medical Source Information - electronic submission Other-Internet Screen	Modified

ICR Details

OMB Control No: 0960-0722	ICR Reference No: 201402-0960-004
Status: Historical Active	Previous ICR Reference No: 201009-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Evidence from Doctor or Hospital
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/02/2014
	Date Received in OIRA: 05/28/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2017	36 Months From Approved	07/31/2014
Responses	528,000	0	528,000
Time Burden (Hours)	132,000	0	132,000
Cost Burden (Dollars)	0	0	0

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Abstract: Sections 223(d)(5) and 1614(a)(3)(H)(i) of the Social Security Act require claimants to furnish medical evidence of their disability when filing a disability claim. SSA uses Forms HA-66 and HA-67 to obtain medical evidence from medical sources identified by the claimants as having information relative to their impairments or ability to do work-related activities. In addition to accepting manual paper responses, SSA sends a barcode with the HA-66 and HA-67 allowing respondents to fax the information directly into the electronic claims folder rather than submitting it manually. SSA uses the information to determine eligibility for benefits. The respondents are medical sources, doctors, and hospitals that evaluate the claimants.

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Authorizing Statute(s): US Code: 42 USC 902 Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 423 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 11852	03/03/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 29834	05/23/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
HA-67 with Medical Source Information - electronic submission
HA-66 with Medical Source Information - paper submission	HA-66	Request for Medical Evidence From a Doctor
HA-67 with Medical Source Information - paper submission	HA-67	Request for Medical Evidence From a Hospital
HA-66 with Medical Source Information - electronic submission

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	528,000	528,000	0	0	0	0
Annual Time Burden (Hours)	132,000	132,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,232,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/28/2014

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