Form SSA-3830 Certification of Low Birth Weight for SSI Eligibility

Form Approved
OMB No. 0960-0720

Social Security Administration

Certification of Low Birth Weight for SSI Eligibility
For SSA Use Only

Requestor

Office Address

Phone #

Fax #

1) Child's SSN (if available)
2) Child's name:

Female
First

Middle

Male

Surname

3) Medical record #:
4) Parents: Mother's name:

Father's name:

Maiden

First

First

Surname

Surname

Phone #

Address

5) Hospital of birth:
6) Date of birth:
7) Weight at birth:

grams

8) Gestational age (GA) at birth:

weeks

9) Medical conditions (check all that apply):
Cerebral white matter insult (periventricular leukomalacia, intraventricular hemorrhage (IVH) grade 3-4, or
ventriculomegaly)
Bronchopulmonary Dysplasia (BPD), also known as Chronic Lung Disease (CLD) of prematurity
Retinopathy of Prematurity (ROP), grade 3 or greater
Necrotizing Enterocolitis (NEC), requiring bowel resection surgery
Other (please specify):

10) Date of discharge (if applicable):

Released to (person/facility):

11) Name and phone number of hospital social worker who can provide information about this child:
Name:
Phone:
OPTIONAL: Attach copy of admission, discharge summary, or other medical evidence.
Form SSA-3830 (10-2009)

-OVER-

Page 1

I certify that the foregoing information is accurate according to the child's medical records.
Physician Signature:
Title:
Date:
Print or type name:
Hospital:
Address:
SEND THE COMPLETED FORM TO THE ADDRESS SHOWN AT THE TOP OF PAGE 1

See Revise Privacy Act

Privacy Act Notice: Sections 1614 and 1633 of the Social Security Act, as amended, and Social
Securityand
regulations
Statement
PRA at
20 C.F.R. §§ 416.931, 416.926a(m)(6) and 416.924 authorize us to collect this information. Statement
The information is needed
to determine benefit eligibility of the named claimant. The information you furnish on this form is voluntary. However,
failure to provide all or part of the information could prevent an accurate and timely decision on benefit eligibility of the
named claimant.
We rarely use the information you supply for any purpose other than for establishing benefit eligibility. However, we
may use it for the administration and integrity of Social Security programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but are not limited to: (1)
to enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or
coverage; (2) to comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veteran Affairs); (3) to make determinations for eligibility in
similar health and income maintenance programs at the Federal, State, and local level; (4) to State agencies or other
agencies providing services to disabled children; and (5) to facilitate statistical research, audit or investigative activities
necessary to assure the integrity of Social Security programs.
We may also use the information you provide in 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 and administered benefit programs and for
repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Records Notice 60-0103 (Supplemental
Security Income Record and Special Veterans Benefits). The notice, additional information regarding this form, and
information regarding our programs and systems, are available on-line at www.ssa.gov or at your local Social Security
office.
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 10-15 minutes to
read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-3830 (10-2009)

Page 2

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 1614 and 1633 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 an accurate and timely decision on the benefit
eligibility of the named claimant.
We will use the information to determine benefit eligibility of the named claimant. We may also
share your information for the following purposes, called routine uses:
1. To representative payees, when the information pertains to individuals for whom they
serve as representative payees, for the purpose of assisting the Social Security
Administration in administering its representative payment responsibilities under the Act
and assisting the representative payees in performing their duties as payees, including
receiving and accounting for benefits for individuals for whom they serve as payees; and
2. To State agencies to enable them to assist in the effective and efficient administration of
the Supplemental Security Income program.
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 and 60-0103, entitled Supplemental Security
Income Record and Special Veterans Benefits. Additional information and a full listing of all
our SORNs are available on our website at www.ssa.gov/privacy/sorn.html.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 (OMB) control number. We estimate that it will take about
15 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.