TN 65 (12-09)

A. The certification of low birth weight for SSI eligibility form (SSA-3830)

The SSA-3830 was created to ensure national uniformity and quality in the documentation of title XVI childhood disability claims in which low birth weight (LBW) is alleged. The SSA-3830 is not required in all LBW claims; however, it must be used whenever the FO or DDS submits a request to a hospital or otherwise provides hospitals with forms for reporting birth weight and other medical information for LBW infants.

B. What is the purpose of form SSA-3830

The purpose of the SSA-3830 is to standardize the information that we request from hospitals about LBW infants and to:

• Provide field offices (FOs) with information for making presumptive disability (PD) decisions in LBW claims.

• Serve as a lead/protective filing statement. See GN 00202.001 Leads and Inquiries, GN 00204.010 Protective Filing, and SI 00601.020 Protective Filing--Written Statement.

• Provide Disability Determinations Services (DDS) adjudicators enough medical information to determine disability under LBW listing 100.04 when signed by a physician.

• Provide DDSs with information for setting the most appropriate continuing disability review diary. See DI 25235.006 Medical Diary Criteria for Low Birth Weight (LBW) Infants under Title XVI.

C. Who uses this form

There are three possible users:

• FOs - when requesting information from hospitals to make PD determinations in LBW claims.

• Hospitals - when arrangements between FOs and local hospitals exist or can be established for notifying FOs of potential LBW disability claims by using an SSA-provided form.

• DDSs - for establishing a medically determinable impairment and making a disability determination when the completed form is signed by a physician.

D. How to use the SSA-3830

Use the SSA-3830:

• To request a hospital to submit information on an SSA-provided form. A hospital is not required to use this form if it submits information by using its own form or providing medical records.

• Accompanied by a signed SSA-827 (Authorization to Release Information to the Social Security Administration).

NOTE: Do not give the form to applicants or third parties to secure information from a hospital.

E. FOs and DDSs may not substitute their own forms for the certification form

This national form (SSA-3830) replaces all locally-produced forms used to obtain information from hospitals in LBW cases. FOs or DDSs may not delete, modify, reword, reorganize, add to, or change in any way the questions presented in this form.

F. Hints for using the SSA-3830

The following hints will be helpful for using the SSA-3830:

• Do not ask a hospital to complete this form if there is a birth certificate in file that has sufficient information for making a PD determination.

• Do not send this form if the FO has already requested the information from the hospital. If there is no form in file, DDSs may send this form as part of their development.

• FOs should stress to hospitals that if a physician signs the completed form, we can make a faster disability determination for the LBW child because, generally, the DDS will require no further medical information.

• The answers to questions 7 and 8 on the form are sufficient for the FO to establish PD due to LBW.

• Question 9 provides the DDS with information that will help them determine the medical diary date. See DI 25235.006 Medical Diary Criteria for Low Birth Weight (LBW) Infants under Title XVI. However, if this question is unanswered, do not return the form to the hospital to answer it.

• File completed form in the medical evidence section of the claims file.

G. Exhibit: Form SSA-3830 (Certification of Low Birth Weight for SSI Eligibility)

To view this form go to SSA-3830.