SSA sends this two-page form to hospitals to get standardized information for a low birth weight infant's SSI disability claim. Signed by a physician from the medical record, it gives disability determination services enough to decide under listing 100.04 and set the review diary, and lets the field office make a presumptive disability finding. SSA's request letter says a physician's signature allows a faster determination.
A hospital physician, typically from the NICU, completes items 1 to 11 and signs the certification on page 2 from the child's medical record. SSA staff may pre-fill items 1 to 6 before sending it.
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Certification of Low Birth Weight for SSI Eligibility
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No. SSA's operations manual says a hospital is not required to use the SSA-3830 if it submits the information on its own form or sends medical records. SSA staff may not alter the form or give it to applicants to take to the hospital; it comes from SSA with a signed SSA-827 authorization.
For a child under one year, field offices can find presumptive disability when evidence shows a birth weight below 1200 grams. For gestational ages of 32 to 40 weeks, the cutoffs rise with age, from 1250 grams or less at 32 weeks to under 2000 grams at 37 to 40 weeks.