Request for Evidence from Doctor or Hospital

ICR 202011-0960-003

OMB: 0960-0722

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Supplementary Document
2020-11-06
Supporting Statement A
2020-11-06
ICR Details
0960-0722 202011-0960-003
Received in OIRA 201703-0960-014
SSA
Request for Evidence from Doctor or Hospital
Revision of a currently approved collection   No
Regular 11/06/2020
  Requested Previously Approved
36 Months From Approved 01/31/2021
528,000 528,000
132,000 132,000
0 0

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.

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
  
None

Not associated with rulemaking

  85 FR 53428 08/28/2020
85 FR 70216 11/04/2020
No

  Total Request 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
No
No

$73,232,175
No
    Yes
    Yes
No
No
No
No
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/06/2020


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