Form SSA-3288 Consent for Release of Information

Social Security Administration

Consent for Release of Information

Instructions for Using this Form

Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an individual or group (for example, a doctor or an insurance company). If you are the natural or adoptive parent or legal guardian, acting on behalf of a minor, you may complete this form to release only the minor’s non-medical records. If you are requesting information for a purpose not directly related to the administration of any program under the Social Security Act, a fee may be charged.

NOTE: Do not use this form to:

• Request us to release the medical records of a minor. Instead, contact your local office by calling 1-800-772-1213 (TTY-1-800-325-0778), or

• Request information about your earnings or employment history. Instead, complete form SSA-7050-F4 at any Social Security office or online at www.ssa.gov/online/ssa-7050.pdf.

How to Complete this Form

We will not honor this form unless all required fields are completed. An asterisk (*) indicates a required field. Also, we will not honor blanket requests for “all records” or the “entire file.” You must specify the information you are requesting and you must sign and date this form.

• Fill in your name, date of birth, and social security number or 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 organization) to whom you want us to release your information.

• Indicate the reason you are requesting us to disclose the information.

• Check the box(es) next to the type(s) of information you want us to release including the date ranges, if applicable.

• You, the parent or legal guardian acting on behalf of a minor, or the legal guardian of a legally incompetent adult, must sign and date this form and provide a daytime phone number where you can be reached.

• If you are not the person whose information is requested, state your relationship to that person. We may require proof of relationship.

PRIVACY ACT STATEMENT

Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. The information you provide will be used to respond to your request for SSA records information or process your request when we release your records to a third party. You do not have to provide the requested information. Your response is voluntary; however, we cannot honor your request to release information or records about you to another person or organization without your consent.

We rarely use the information provided on this form for any purpose other than to respond to requests for SSA records information. However, in accordance with 5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the information provided on this form in accordance with approved routine uses, which include but are not limited to the following:

1. To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level;

3. To comply with Federal laws requiring the disclosure of the information from our records; and,

4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of SSA programs.

We may also use the information you provide when we match records by computer. Computer matching programs compare our records with those of other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person’s eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

Additional information regarding this form, routine uses of information, and other Social Security programs are available from our Internet website at www.socialsecurity.gov or at your local Social Security office.

PAPERWORK REDUCTION ACT STATEMENT

This information collection meets the 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. You can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U.S. Government agencies in your telephone directory or you may call 1-800-772-1213 (TYY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Social Security Administration

Consent for Release of Information

SSA will not honor this form unless all required fields have been completed (*signifies required field).

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 selected from the list below:

You must check at least one box. Also, SSA will not disclose records unless applicable date ranges are included.

 Social Security Number

 Current monthly Social Security benefit amount

 Current monthly Supplemental Security Income payment amount

 My benefit/payment amounts from __________ to __________

 My Medicare entitlement from __________ to __________

 Medical records from my claims folder(s) from __________ to __________

If you want SSA to release a minor’s medical records, do not use this form but instead contact your local SSA office.

 Complete medical records from my claims folder(s)

 Other record(s) from my file (e.g. applications, questionnaires, consultative examination reports,

determinations, etc.) ___________________________________________________________

___________________________________________________________________________________________

I am the individual to whom the requested information/record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. I declare under penalty of perjury in accordance with 28 C.F.R. § 16.41(d)(2004) that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeking or obtaining access to records about another person under false pretenses is punishable by a fine of up to $5,000. I also understand that any applicable fees must be paid by me.

*Signature: ____________________________________________________ *Date: ___________________

Relationship (if not the individual): ________________________ *Daytime Phone _______________________

SSA-3288