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OMB Control No: 0960-0803	ICR Reference No: 202607-0960-007
Status: Received in OIRA	Previous ICR Reference No: 202301-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement From Excluded Medical Sources of Evidence
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 07/31/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2026
Responses	2,710	600
Time Burden (Hours)	903	200
Cost Burden (Dollars)	0	0

Abstract: Section 812 of the Bipartisan Budget Act of 2015 (BBA), “Exclusion of certain medical sources of evidence,” mandates that SSA exclude evidence in disability decisions from certain medical sources. BBA Section 812 amended section 223(d)(5) of the Social Security Act (Act) by adding a subsection “C.” 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. We also implemented section 223(d)(5)(C), as amended, through regulations at 20 CFR 404.1503b and 416.903b of the Code of Federal Regulations. These regulations 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 applies to evidence they submit to SSA directly, or through a representative, claimant, or other individual or entity. As needed, SSA informs the medical sources we suspect should be excluded of these requirements through a Fact Sheet we send to them via mail, or which they can find on our website where we list the regulatory requirements under BBA section 812. In addition, along with the Fact Sheet and website, we provide sample statements as templates the affected medical sources can use to create their own written statements as required under our regulations. 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; (2) furnish evidence related to a claim for benefits under Titles II or XVI of the Act; and (3) had failed to self-identify as an excluded source of medical evidence as required in section 223(d(5)(C)(i).

Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
   PL: Pub.L. 114 - 74 812 Name of Law: Bipartisan Budget Act of 2015
   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:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 30774	05/26/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 48475	07/31/2026
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
20 CFR 404.1503b(c) - Fact Sheet
20 CFR 416.903b(c) - Follow-up Notice

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	2,710	600	80	2,030
Annual Time Burden (Hours)	903	200	26	677
Annual Cost Burden (Dollars)	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: When we cleared the this ICR in 2023, the burden was 200 hours. However, we are currently reporting a burden of 903 hours. This change stems from both an increase in individuals reported to us who are initially identified as excluded sources of evidence – currently estimated at 2,670 (to whom we send the Fact Sheet informing them of their excluded status and our rules regarding the required statement), but also an overall decrease in the number of respondents who submit medical evidence without the required statement – currently estimated at 40 (to whom we send the follow-up notice). This demonstrates that there are fewer individuals who are either unfamiliar with our rules regarding the statement or who do not comply with our rules upon learning of them. Although the overall number of individuals identified as excluded sources has increased (which largely accounts for the increased annual cost to the Federal government due to the need to initially send the Fact Sheets), SSA continues to observe fewer excluded sources who submit evidence to us either without the required statement, or who submit evidence at all, as the years progress. These figures represent current Management Information data.

Annual Cost to Federal Government: $96,116

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

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? No

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

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