Supporting Statement 0722

Supporting Statement for Request for Evidence from Doctor (HA-66) and Evidence from Hospital (HA-67)

20 CFR 404 Subpart P and 20 CFR 416 Subpart I

OMB No. 0960-0722

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 702(a)(5) of the Social Security Act (Act) allows the Commissioner of the Social Security Administration (SSA) to prescribe such rules and regulations as the Commissioner determines necessary to administer the Social Security programs, under Title II of the Act, and the Supplemental Security Income program, under Title XVI of the Act. Sections 205(a) and 1631(d) of the Act require the Commissioner to regulate the method of taking and furnishing evidence to establish the rights to benefits or payments under Titles II and XVI. A claimant for benefits based on disability is responsible for furnishing medical evidence of disability as set forth in Sections 223(d)(5) and 1614(a)(3)(H)(i) of the Act. These sections also require the Commissioner to develop a complete medical history of at least the twelve months preceding the month of the application for benefits in any case in which SSA determined the individual is not disabled.

The Commissioner published regulations on determining disability and blindness, as set forth at 20 CFR 404 Subpart P and 20 CFR 416 Subpart I of the Code of Federal Regulations. Sections 404.1512 and 416.912 describe the responsibilities of the claimant to submit evidence of disability, and of the Commissioner to develop a complete medical history before determining a claimant is not disabled. Sections 404.1513(a) and 416.913(a) describe acceptable sources of medical and other evidence necessary to establish impairment. Sections 404.1513(b) and 416.913(b) describe the type of information necessary to establish the existence and extent of a medically determinable impairment. Sections 404.1513(e) and 416.913(e) require SSA to create complete and detailed evidence in the case file, including the evidence from medical sources, to allow us to determine, among other things, the individual’s residual functional capacity to do work-related activities. Sections 404.1514 and 416.914 explain how SSA will pay medical sources the reasonable cost of providing us any existing medical evidence we need and request.

2. Description of Collection

SSA uses Forms HA-66 and HA-67 to request evidence from medical sources, which claimants identify 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, and to pay medical sources for furnishing the information. The respondents are medical sources, doctors, and hospitals that evaluate the claimants.

3. Use of Information Technology to Collect the Information

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. In addition, SSA’s Electronic Records Express (ERE) website, approved under OMB Number 0960-0753, permits and encourages direct electronic submission of medical records, and offers major advantages in speed, efficiency, and tracking of information, particularly for medical providers using health information technology. Approximately 75% of the medical sources respond electronically through ERE.

SSA is unable to create an electronic version of this information collection at this time, as we send this agency-initiated application to respondents with pre-filled information.  We also include a bar code which allows us to scan the completed form into the electronic folder once we receive it from the respondent.  Currently, we do not have any means to pre-fill information and send the individualized forms to the respondents electronically, as that would require us to build a new system, and we do not have the resources and manpower to do that at this time.  In addition, we cannot send these via email, as the pre-filled information contains personal identifying information (PII) of the respondents, and email is a non-secured means of transferring PII.  We will reassess our ability to create an electronic version of this collection if and when technological advances are created that would allow for us to make this collection available via the Internet in a fully secure way.

4. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

In accordance with sections 223(d)(5)(A) and 1614(a)(3)(H) of the Act, we compensate the respondents for providing medical reports. In addition, the ALJs only collect the information they require to make a disability determination for the claimant. As such, we minimized the effect on small entities to the extent possible.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

SSA requires this information to ensure the ALJ obtains all pertinent medical information before reaching a disability decision within the confines of the Act. If we did not collect this information, disabled individuals might not receive the benefits for which they are eligible. Since we only collect this information on as needed bases, we cannot collect it less frequently. There are no technical or legal obstacles that prevent burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on August 28, 2020, at

85 FR 53428, and we received no public comments. The 30-day FRN published on November 04, 2020 at 85 FR 70216. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

9. Payment or Gifts to Respondents

To compensate the doctors and hospitals providing medical reports, we require entities to complete the included Medical Source Information Request on Page 3 of the HA‑66 or HA-67, or submit the same information on a separate invoice, indicating the amount they charge for providing the report.

10. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Total Annual Opportunity Cost (dollars)**
HA-66 – Paper Version	3,060	22	15	16,830	$40.21	$676,734**
HA-66 –Electronic Version (ERE or barcode)	8,940	22	15	49,170	$40.21	$1,977,126*
HA-67 – Paper Version	3,060	22	15	16,830	$40.21	$676,734**
HA-67 – Electronic Version (ERE or barcode)	8,940	22	15	49,170	$40.21	$1,977,126**
Totals	24,000			132,000		$5,307,720**

* We based this figures on average U.S. citizen’s hourly salary, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes290000.htm).

** We based this figure on the average FY 2020 wait times for field offices, based on SSA’s current management information data.

*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

The total burden for this ICR is 132,000 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $5,307,720. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $73,232,175.  This estimate accounts for costs from the following areas

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars
Designing and Printing the Form	Design Cost + Printing Cost	$175
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	0
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$7,2000,000
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	0
Systems Development, Updating, and Maintenance	GS employee x man hours for development, updating, maintenance	$1,232,000
Quantifiable IT Costs	Any additional IT costs	0
Total		$73,232,175

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have.  First, since we work with almost every US citizen, we often do bulk mailings, and cannot track the cost for a single mailing.  In addition, it is difficult for us to break down the cost for processing a single form, as field office and State Disability Determination Services staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes to the public reporting burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

SSA is not requesting an exception to the requirement to display the OMB approval expiration date for the ERE collection; however, we discuss ERE within its own information collection request under OMB Control Number 0960-0753.

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at

5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collection of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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