Medical evidence is a statement offered by a physician, psychologist, or other qualified medical practitioner (medical source), based on their evaluation, examination, or treatment of the beneficiary, which provides a meaningful assessment on the beneficiary’s ability to manage or direct the management of benefits. All medical evidence used for making the capability decision must be submitted by a medical source who conducted the examination or a person authorized to provide such certifications (e.g., a medical records librarian).

The SSA-787, Medical Source Opinion of Patient’s Capability to Manage Benefits, is the preferred vehicle for obtaining medical evidence of capability. However, you may use other forms and summary reports from the medical source instead of the SSA-787, if:

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  The medical source (physician, psychologist or other qualified medical practitioner) noted in the other form or summary report that they have knowledge of the claimant's medical condition as it relates to the beneficiary's ability to manage or direct the management of funds;

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  It includes a basis for their assessment, e.g., observations, medical records, diagnostic tests, patient self-report, family member's report; and

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  It is dated.

For instructions for medical evidence that is less than one year old, follow GN 00502.040A.2.a.

For instructions for medical evidence that is over one year old, follow GN 00502.040A.2.b

For instructions when there is no medical evidence, follow GN 00502.040B.

NOTE: For information on using the disability listing 12.05A as medical evidence, see GN 00502.040A.9.

If the beneficiary had an evaluation, examination, or treatment by a medical source within the past year, you must obtain a signed and dated SSA-827 Authorization to Disclose Information to the Social Security Administration. You must send the SSA-787 and SSA-827 directly to the medical source to obtain medical evidence that is less than one year old. Follow instructions for completing the SSA-827 in DI 11005.055.

The beneficiary or representative (someone who can act under State law in making decisions related to beneficiary health care) must sign the SSA-827, or an alternative Health Insurance Portability and Accountability Act (HIPAA)-compliant authorization form, to disclose medical information. If the beneficiary refuses to sign the form, and has no representative, and there is no older evidence in SSA records, per GN 00502.040A.2.b, you must develop capability using other evidence, per GN 00502.040B.

If the beneficiary decides to undergo an evaluation, examination, or obtain treatment on their own volition, ask the beneficiary to notify SSA after the examination. Then mail a SSA-787, and signed and dated SSA-827, to the medical source. If the beneficiary is unwilling to undergo an evaluation, examination, or treatment, do not compel them to do so solely to obtain medical evidence of capability.

If you receive the SSA-787, but you question the authenticity, follow GN 00502.040A.5.

For an incomplete SSA-787, other form, or summary report, follow GN 00502.040A.6.

IMPORTANT: If you receive a completed other form or summary report back from the medical source, i.e., not the SSA-787, you can accept it, but only if it fits the criteria in GN 00502.040A.1.

The medical source may mail or fax the completed SSA-787, other form, or summary report, directly back to SSA. Accept the original document or photocopy. If the medical source provided the completed SSA-787, other form, or summary report to the beneficiary instead of SSA, follow the instructions in GN 00502.040A.5.

IMPORTANT: If you question the authenticity of the SSA-787, other form, or summary report, follow GN 00502.040A.5.

REMINDER: If the medical evidence is not the SSA-787, but another form or summary report, you can only accept it if it also fits the criteria in GN 00502.040A.1.

For an incomplete SSA-787, other form, or summary report, you must follow GN 00502.040A.6.

If you question the authenticity of the SSA-787, other form, or summary report, you must contact the medical source, or medical source’s representative, to confirm its authenticity and verify the contents. You must document the details of contacts with medical sources as follows:

If you receive an incomplete SSA-787, other form, or summary report, directly from a medical source, contact the medical source of the evidence for confirmation. If the medical source confirms providing the incomplete evidence, redevelop by sending an SSA-787 and SSA-827 to this medical source. The confirmation may be from the medical source who provided the SSA-787, other form, or summary report, or the medical source’s representative.

You must document the details of your contact with the medical source, per GN 00502.040.A.5.

SSA does not pay for medical evidence used solely to decide capability. If the medical source requests payment for medical evidence of capability, do not honor the request. Explain that since we will not use the evidence in deciding entitlement, SSA cannot pay for it. If the medical source refuses to provide the evidence without payment and there is no other medical evidence available per GN 00502.040A, develop capability using other evidence, per GN 00502.040B.

In disability cases, DDS often gives an opinion regarding the beneficiary’s capability. DDS is not responsible for making capability determinations.

DDS opinion is lay evidence of capability; it is NOT a determination on capability.

DDS is responsible for providing an opinion regarding a claimant’s capability to manage their disability benefits when the field office (FO) identifies a case where it is likely that a claimant may be incapable or where DDS medical development indicates the claimant may be incapable, per DI 23001.001. While the DDS provide an opinion regarding the evidence of capability, the FO is responsible for the final determination of capability. DDS does not complete medical development solely to resolve an issue of capability, per DI 23001.005.

If you are referring your case to the DDS for a disability determination, you can request DDS assistance in obtaining medical evidence of capability by following the instructions in:

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  DI 11055.215 Resolving Representative Payee Issues;

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  DI 11005.045 Completing the SSA-3367;

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  DI 23001.001 Disability Determination Services (DDS) Capability Opinion; and

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  DI 23001.005 Disability Services (DDS) Procedures for Developing Capability.

In cases where DDS initiates capability development, the DDS enters its opinion in the remarks section of the Forms SSA-831-U3 (Disability Determination and Transmittal), SSA-832-U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal) for Title XVI, or the SSA-833-U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal) for Title II.

If the file contains a completed SSA-831-U3, SSA-832-U3, or SSA 833-U3 from the DDS with no opinion on capability, do not seek a DDS opinion on capability even if you have doubts about the beneficiary’s capability. Develop capability using other information.

If you do not need a disability determination, or if the DDS indicates on the Form SSA-831-U3 (Disability Determination and Transmittal) that capability is unresolved, contact the medical source for medical evidence of capability.

Disability listings appear on the SSA-831-U3, in item 23. They may be referred to in Administrative Law Judge or Appeals Council decisions. A disability allowance under disability listing 12.05A is medical evidence only of incapability and you must consider the medical evidence along with lay evidence to conduct a full capability determination. For more information on DDS procedures for developing capability, see DI 23001.005.

If the medical source works at a VA facility, include a signed and dated SSA-827 with your request (e.g., your request may be the SSA-787).

It is important to use good judgment to weigh the value of the medical evidence before you make a capability determination based on it. For example, a medical statement of capability from a consultative examiner or another medical source based on limited contact with the beneficiary is less convincing than a statement from the beneficiary’s own medical source.

Likewise, a medical statement based on an evaluation, examination, or treatment of more than one year ago is not as valuable as medical evidence that is less than one year ago. To arrive at a sound and well-reasoned capability determination, you must carefully evaluate the medical evidence obtained for each case, along with all other evidence (namely, lay evidence, see GN 00502.030.)