TN 33 (11-12)
DI 23535.013 Using the Certification of Low Birth Weight for Supplemental Security Income Eligibility (Form SSA-3830)
20 CFR §§ 416.924, and 416.931
A. Disability Determination Services (DDS) usage policy for the certification of low birth weight (LBW) for supplemental security income (SSI) eligibility form
Form SSA-3830 ensures national uniformity and quality in the documentation of SSI childhood disability claims in which LBW is a consideration. Whenever submitting a request to a hospital for reporting birth weight and other medical information for LBW infants, include Form SSA-3830.
NOTE: If there is no form in the file, the DDS may send this form as part of medical evidence development.
B. Purpose of Form SSA-3830
The SSA-3830 is an Office of Management and Budget (OMB) approved form that standardizes the information we request from hospitals about LBW infants and:
provides DDS adjudicators enough medical information to determine disability under LBW listing 100.04;
provides DDS adjudicators with information for setting the most appropriate continuing disability review diary (see DI 25235.006);
provides field office (FO) with information for making presumptive disability (PD) findings in LBW claims; and
serves as a lead or protective filing statement.
C. DDSs must not substitute other forms for the SSA-3830
Use Form SSA-3830 to obtain information from hospitals in LBW claims. Do not delete, modify, reword, reorganize, add to, alter, or change the questions in this OMB-approved form.
D. Who uses the SSA-3830 and why
The DDS, FO, and hospitals use the SSA-3830 for the following purposes.
DDS – to establish a medically determinable impairment and make a disability determination (when signed by a physician).
FO – to request information from hospitals to make a PD finding in LBW claims.
Hospitals – to notify FOs of potential LBW disability claims by using a Social Security Administration SSA-provided form.
NOTE: A hospital is not required to use the SSA-3830 if the hospital submits information by using its own form or provides medical records.
E. Using the SSA-3830 in medical evidence of record (MER) development
1. Expedite LBW claims
The SSA-3830 is not a mandatory part of development in every LBW claim. However, if an adjudicator opts to send a form to obtain information regarding claims alleging LBW, use the SSA-3830 instead of a locally developed form.
Send the SSA-3830 to request information from the hospital to expedite development of LBW claims and include a signed Form SSA-827 Authorization to Disclose Information to the Social Security Administration (SSA).
IMPORTANT: If the information on the completed SSA-3830 does not support a fully favorable LBW allowance, develop the claim.
2. Request for MER
The SSA-3830 does not replace the DDS’s standard hospital MER request. As the SSA-3830 is an expedient, consider faxing the form rather than including it in the normal MER request. Contact the hospital’s social service or patient resources department to coordinate timely completion.
3. Cover letter
Include a cover letter if the SSA-3830 is not sent as part of the standard MER request. For content guidance, see DI 22505.021B.
Use agency or local DDS letterhead.
Explain that if a physician signs the completed form, we can make a faster disability determination for the LBW child.
Do not request a medical source statement.
We do not pay for completion of the form.
Follow standard MER follow up procedures.
F. When not to send the SSA-3830
Do not send the SSA-3830 if:
the form is already in the file;
there is sufficient medical evidence (e.g., a birth certificate) in file to make a PD finding or fully favorable determination.
NOTE: Do not give the form to applicants or third parties to secure the information from the hospital.
G. Folder documentation
Insert the completed form in the medical evidence section of the official folder. If the official folder is a Certified Electronic File (CEF), create a bar code and fax the document into section F.
H. Exhibit of the Certification of Low Birth Weight for SSI Eligibility (Form SSA-3830)
To view the form, go to SSA-3830.
The DDS can fill in items 1 through 6, print, and send the form to the hospital for completion.
NOTE: The SSA-3830 is not currently available in Form Selector.
DI 11055.242 Using the Certification of Low Birth Weight for SSI Eligibility (SSA-3830) Form in Making Presumptive Disability Determinations
DI 25235.006 Medical Diary Criteria for Low Birth Weight (LBW) Infants under Title XVI