Current SSA-3288

Social Security Administration

Form Approved
OMB No. 0960-0566

Consent for Release of Information
Please read these instructions carefully before completing this form.
When to Use
This Form

Complete this form only if you want the Social Security Administration to give
information or records about you to an individual or group (for example, a doctor
or an insurance company).
Natural or adoptive parents or a legal guardian, acting on behalf of a minor, who
want us to release the minor's:
· nonmedical records, should use this form.
· medical records, should not use this form, but should contact us.
Note: Do not use this form to request information about your earnings or employment
history. To do this, complete Form SSA-7050-F4. You can get this form at any
Social 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
nonmedical information applies, or
the legal guardian of a legally incompetent adult to whom the
information applies.
To complete this form:
· Fill in the name, date of birth, and Social Security Number of the person to whom
the information applies.
· Fill in the name and address of the individual or group to which we will send the
information.
· Fill in the reason you are requesting the information.
· Check the type(s) of information you want us to release.
· Sign and date the form. If you are not the person whose record we will release,
please state your relationship to that person.

PRIVACY ACT NOTICE: The Privacy Act Notice requires us to notify you that we are authorized to collect
this information by section 3 of the Privacy Act. You do not have to provide the information requested.
However, we cannot release information or records about you to another person or organization without your
consent for release of information. Your records are confidential. We will release only records that you
authorize, and only to persons or organizations who you authorize to receive that information.
PAPERWORK REDUCTION ACT STATEMENT: This information collection meets the clearance requirements
of 44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer
these questions unless we display a valid Office of 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 OR BRING
THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under
U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You
may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 212345-6401. Send
only comments relating to our time estimate to this address, not the completed form.

Form SSA-3288 (5-2007) EF (5-2007)

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 to 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 benefits/payments I received from
to
Information about my Medicare claim/coverage from
to
(specify)
Medical records
Record(s) from my file (specify)
Other (specify)
I am the individual to whom the information/record applies or that person's
parent (if a minor) or legal guardian. I know that if I make any representation
which I know is false to obtain information from Social Security records, I could
be punished by a fine or imprisonment or both.
Signature:

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

Date:
Form SSA-3288 (5-2007) EF (5-2007)

Relationship: