Form SSA-3288 Consent for Release of Information

P m Approved
OMB NO.0960-0566
S d a I Security Administration

Consent for Release of Information
Piease read these hslructions carefully before completing Chis form.

When to Use
Thfs Form

Complete this form only if yon want the Social $amity Administration to
give information or records about you to an individual or group (for
example, a doctor, or an insumwe company).
Natural or adoflve pards or a I@ guardian, h g on behalf of a
minor, who want us to release tbe minor's:
nonmedid records, should use this h.
medical records, should not use this form, but should contact us.
Note: Do not use this form to request information about yaur wrings or
employment history. To do this, complete Form SS A-7050-F4. You can get
this f m at any W i a l Security office.

How to
Complete
This Form

This consent form must be completed and signed only by:
the person to whom the information or record applies, or
the parent or legal guardian of a minor to whom the n o d d
information applies, or
the legal guardian of a legally incompetent adult to whom the information
appIies.

To complete this form:
Fill in the name, date of birth, armd Social Security Number of the fwrson to
whom the information applies,
Fill in the aame and address of the individwd or group to which we will
send the information.
FiU in the reason you are requesting the information.
Check the m
a
)of information you want us to release.
Sign and date the form. If yw are not the person whose record we will
release, please state your relationship to that person.

Form SSA-3288 (3-205) EP (3-2005)

Form Approved
OMB No. 0960-0566

Social Security Administration

Consent for Release of Information
TO: Social Security Administration
Name

Date of Birth

Social Security Number

I authorize the Social Security Administration t o release information or records about

me to:
NAME

ADDRESS

I want this information released because:

(There may be a charge for releasing information.)

Please release the following information:

-

Social Security Number
Identifying information (includes date and place of birth, parents' names)
Monthly Social Security benefit amount
Monthly Supplemental Security Income payment amount
Information about benefitstpayments I received from
to
Information about m y Medicare claimlcoverage from
to
(specify 1
Medical records
Record(s) from my file (specify)
Other (specify)

I am the individual to whom the informationlrecord applies or that person's parent (if a
minor) or legal guardian. I declare under penalty of perjury that I have examined all the
information on this form and it is true and correct to the best of my knowledge. I
understand that anyone who knowingly gives a false or misleading statement about a
material fact in this information, or causes someone else to do so, commits a crime and
may be sent t o prison, or may face other penalties, or both.

Signature:
(Show signatures, names, and addresses of two people if signed by mark.)

Date:

Relationship:

Thefol[owi~grevised PRA Statement will be inserted into the form at its
nexi sch~dulcdreprinting:
Paperwork Reduction Act Statement - This information coIIection meets the
requirements of 44 U.S.C. 5 3507, as amended by section 2 of the Paperwork Reduction
Act of 1 995. You do not need to answer these questions unless we display a valid Office
o f Management and Budget control number. We estimate that it will take about 3
minutes to read the instructions, gather the facts, and answer the questions. SEND O R
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office i s listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213. Yorr mqv send comments
an or~rlime rrstimatr above to: SSA, 6401 Security Blvd, BaJtimore, MD 21235-64Of.
Send & cornmenfs refating to o w t i ~ ~estimate
te
to this addre.r.y,
the cempfeted
fnrnt.