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OMB Control No: 0960-0803	ICR Reference No: 201609-0960-014
Status: Historical Active	Previous ICR Reference No: 201606-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Evidence From Excluded Medical Sources of Evidence
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/30/2016
	Date Received in OIRA: 09/23/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved
Responses	3,000	0	0
Time Burden (Hours)	1,000	0	0
Cost Burden (Dollars)	0	0	0

Abstract: Section 812 of the Bipartisan Budget Act of 2015 (BBA 812) amends section 223(d)(5) of the Social Security Act (Act) by adding a subsection “C.” BBA 812 mandates that the Social Security Administration (SSA) implement the provisions of amended section 223(d)(5)(C)(i) by regulation by November 2, 2016. Section 223(d)(5)(C)(i) of the Act, as amended, requires SSA to exclude evidence (except for good cause) from medical sources: (1) convicted of a felony under sections 208 or 1632 of the Act; (2) excluded from participating in any Federal health care program under section 1128 of the Act; or (3) imposed with a civil monetary penalty (CMP), assessment, or both, for submitting false evidence, under section 1129 of the Act. These final, new regulations will require excluded medical sources to self-report their excluded status in writing each time they submit evidence related to a claim for benefits under Titles II or XVI of the Act. Excluded medical sources’ duty to self-report their excluded status will apply to evidence they submitted to SSA directly or through a representative, claimant, or other individual or entity. The self-report will include: (1) the heading "WRITTEN STATEMENT REGARDING SECTION 233(d)(5)(C) OF THE SOCIAL SECURITY ACT - DO NOT REMOVE[,]" (2) the name and title of the affected source; and (3) the applicable excluding event (i.e., felony conviction, section 1128 exclusion, or CMP or assessment under section 1129). Felons must also include their date of conviction, and those imposed with a CMP must provide the dates of imposition. Sources excluded under section 1128 must include: (1) the basis of their exclusion; (2) its effective date and anticipated length, and (3) whether the Department of Health and Human Services' Office of Inspector General waived it. The respondents for this collection are medical sources that (1) meet one of the exclusionary categories set forth in section 223(d)(5)(C)(i) of the Act, as amended, and (2) furnish evidence related to a claim for benefits under Titles II or XVI of the Act.

Authorizing Statute(s): PL: Pub.L. 114 - 74 812 Name of Law: Bipartisan Budget Act of 2015
   US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 902 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act

Citations for New Statutory Requirements: PL: Pub.L. 114 - 74 812 Name of Law: Bipartisan Budget Act of 2015

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0960-AH92	Final or interim final rulemaking	81 FR 65536	09/23/2016

Federal Register Notices & Comments
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
20 CFR 404.1503b(c) & 416.903b(c)

ICR Summary of Burden

	Total Approved	Change Due to New Statute
Annual Number of Responses	3,000	3,000
Annual Time Burden (Hours)	1,000	1,000
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This new information collection increases the public reporting burden. See chart above for updated burden figures.

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

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