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View ESA-OWCP-DCMWC's Form 1215-0173 Online 
| Agency: |
ESA-OWCP-DCMWC |
| Title: |
CM-787, Physician's/Medical Officer's Statement |
| Form Description: |
CM-787, Physician's/Medical Officer's Statement: Benefits due a black lung beneficiary may be paid to another person on behalf of the entitled individual when the beneficiary is unable to manage his or her own financial affairs. To determine incapability or incompetence, certain medical information needs to be obtained from a physician. The CM-787 is completed by a physician to attest to the beneficiary’s ability to manage benefit payments. |
| OMB Control Number: |
1215-0173 |
| OMB Expiration Date: |
Friday, October 31, 2008
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