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Form Ssa-787 - Physician'S/medical Officer'S Statement Of Patient'S Capability To Manage Benefits Page 2

1. Date you last examined the patient _______________________________________

2. Do you believe the patient is capable of managing or directing the management of benefits in his or her own best interest?

By capable we mean the patient:

• is able to understand and act on the ordinary affairs of life, such as providing for own adequate food, housing, clothing,

etc., and

• is able, in spite of physical impairments, to manage funds or direct others how to manage them.

Yes

Unsure

If "No", please provide a brief summary of the findings

If "Unsure", please explain.

If "Yes", please omit question 3,

that led to this conclusion. Also, complete question 3.

but be sure to sigh and date the form.

3. Do you expect the patient to be able to manage funds in the future (for example, the patient is temporarily unconscious)?

Yes

If yes, please explain.

HEREBY CERTIFY THAT THE ABOVE STATEMENTS AND ANSWERS ARE TRUE TO THE BEST OF MY KNOWLEDGE.

NAME OF PHYSICIAN/MEDICAL OFFICER (Please print)

TITLE

ADDRESS (Number and street, City, State, And ZIP Code)

TELEPHONE NUMBER (Including Area Code)

(

)

NATURE OF PHYSICIAN/MEDICAL OFFICER

DATE

FORM SSA-787 (7-92)

*U.S. Government Printing Office: 1994 --300-948/00029

Form Ssa-787 - Physician'S/medical Officer'S Statement Of Patient'S Capability To Manage Benefits Page 2