Addendum to the Supporting Statement for 0960-0566

Addendum to the Supporting Statement for SSA-3288

Consent for Release of Information

20 CFR Parts 401 and 402

OMB No. 0960-0566

Revision to the Collection Instrument

• Change #1: We are changing the language in page one, “Instructions for Using this Form”:

• Old Language:

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). You may complete this form to release only the minor’s non-medical records if you are the natural or adoptive parent or legal guardian, acting on behalf of a minor child. We may charge a fee for providing the information if you are requesting the information for a purpose unrelated to the administration of a program under the Social Security Act.

NOTE: Do not use this form to:

• Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our toll-free number, 1-800-772-1213 (TTY-1-800-325-0778), or

• Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You can obtain form SSA-7050-F4 from your local Social Security office or online at www.ssa.gov/online/ssa-7050.pdf.

• New Language:

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). You may complete this form to release only the minor’s non-medical records, if you are the natural or adoptive parent or legal guardian, acting on behalf of a minor child. We require proof of relationship, if you are not the subject of the record. We may charge a fee for providing the information, if you are requesting the information for a purpose unrelated to the administration of a program under the Social Security Act. If you are requesting information, such as a Social Security Statement or benefit verification letter, you can also access this information by creating an account at https://www.ssa.gov/myaccount/.

NOTE: Do NOT use this form to request:

• The release of a minor child’s medical records. Instead, visit your local Social Security office or call our toll-free number, 1-800-772-1213 (TTY-1-800-325-0778), or

• Detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You can obtain form SSA-7050-F4 from your local Social Security office or online at www.ssa.gov/online/ssa-7050.pdf.

Justification #1: We are making this language change for clarification purposes.

• Change #2: We are changing the language in page one, “How to Complete this Form”:

• Old Language:

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 “any and all records” or the “entire file.” You must specify the information you are requesting and you must sign and date this form. We may charge a fee to release information for non-program purposes.

• 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 requested information pertains.

• Fill in the name and address of the person or organization where you want us to send the requested information.

• Specify the reason you want us to release information.

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

• For non-medical information, you, the parent or legal guardian acting on behalf of a minor or legally incompetent adult, must sign and date this form and provide a daytime phone number.

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

• New Language:

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 “any and all records” or the “entire file.” You must specify the information you are requesting and you must sign and date this form.

• Fill in the name, date of birth, and social security number of the subject of the record.

• Fill in the name and address of the person or organization of where you want us to send the requested information.

• Specify the reason you want us to release the information (e.g., litigation, investigation, determining eligibility for benefits). If you are the natural or adoptive parent or legal guardian, acting on behalf of a minor child or legally incompetent adult, you must state how the release of information is in the best interest of the minor child or legally incompetent adult.

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

NOTE: Unless otherwise specified, the consent form is valid for one-time use only. Also, it is valid for one year from the date of signature, unless you are requesting medical records. A consent form that includes a request for medical records is valid for 90 days from the date of signature.

Send or bring the completed form to the subject of the record’s local servicing office. To locate the appropriate servicing office, visit https://secure.ssa.gov/ICON/main.jsp, and input the subject of the record’s zip code.

Justification #2: We are making this language change for clarification purposes.

• Change #3: We are changing the language in page one, “Privacy Act Statement”:

• Old Language:

Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. We will use the information you provide to respond to your request for access to the records we maintain about you or to process your request to 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. We use information from these matching programs 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.

• New Language:

The Privacy Act (5 U.S.C. 552a) and Section 205(a) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from honoring the request to release information or records about you. We will use the information you provide to respond to the request for Social Security Administration (SSA) records. We may share the information for the following purposes, called routine uses:

• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of its programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0320, entitled Electronic Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210; and 60-0340, entitled FOIA and Privacy Act Record Request and Appeal System, as published in the FR on July 13, 2016, at 81 FR 45352. Additional information, and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy.

Justification #3: SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the form.

• Change #4: We are changing the language in page one, “Paperwork Reduction Act Statement”:

• Old Language:

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.

• New Language:

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. 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.

Justification #4: We are revising the PRA statement to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.

• Change #5: We are changing the language in page two, “Consent for Release of Information”:

• Old Language:

You must complete all required fields. We will not honor your request unless all required fields are completed. (*Signifies a required field. **Please complete these fields in case we need to contact you about the consent form.)

__________ _____________ ________________________

* Full Name * Date of Birth * Social Security Number

• New Language:

You must complete all required fields. We will not honor your request unless all required fields are completed. (*Signifies a required field. **These are not mandatory fields for the consent form to be acceptable. Please complete these fields in case we need to contact you about the consent form.)

__________ _____________ __________________________

* Full Name * Date of Birth * Full Social Security Number

Justification #5: We are making this language change for clarification purposes.

• Change #6: We are changing the language in page two, “I authorize the Social Security Administration to release information or records about me to”:

• Old Language:

*NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:

______________________________ ________________________________

• New Language:

*NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:

**PHONE NUMBER OF PERSON OR ORGANIZATION:

______________________________ ________________________________

Justification #6: We are making this language change for clarification purposes.

• Change #7: We are changing the language in page two, “Please release the following information selected from the list below”:

• Old Language:

Check at least one box. We will not disclose records unless you include date ranges where applicable.

1.  Verification of Social Security Number

2.  Current monthly Social Security benefit amount

3.  Current monthly Supplemental Security Income payment amount

4.  My benefit or payment amounts from date __________ to date__________

5.  My Medicare entitlement from date __________ to date __________

6.  Medical records from my claims folder(s) from date__________ to date__________

If you want us to release a minor child’s medical records, do not use this form. Instead, contact your local Social Security office.

7.  Complete medical records from my claims folder(s)

8.  Other record(s) from my file (We will not honor a request for “any and all records” or “the entire file.” You must specify other records; e.g., consultative exams, award/denial notices, benefit applications, appeals, questionnaires, doctor reports, determinations.)

_____________________________________________________________________

• New Language:

Check at least one box. If requesting medical records, do not check both boxes 7 and 8. We will not disclose records unless you include specific date ranges where applicable.

1.  Verification of Social Security Number

2.  Current monthly Social Security benefit amount

3.  Current monthly Supplemental Security Income payment amount

4.  Social Security benefit amounts from date __________ to date__________

5.  Supplemental Security Income payment amounts from date __________ to date__________

6.  Medicare entitlement from date __________ to date__________

7.  Medical records from date __________ to date __________

8.  Complete medical records

9.  Other Social Security record(s) (We will not honor a request for “any and all records” or “the entire file.” You must specify which records you are seeking. For example, award/denial notices, benefit applications, appeals)

_____________________________________________________________________

Justification #7: We are making this language change for clarification purposes.

• Change #8: We are changing the language in the Penalty of Perjury statement, in page two:

• Old Language:

I am the individual, to whom the requested information or 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 (28 CFR § 16.41(d)(2004)) 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 or willfully seeks or obtain access to records about another person under false pretenses is punishable by a fine of up to $5,000. I also understand that I must pay all applicable fees for requesting information for a non-program-related purpose.

• New Language:

I am the individual, to whom the requested information or 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 (28 U.S.C. § 1746) 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 or willfully seeks or obtains access to records about another person under false pretenses is punishable by a fine of up to $5,000.

Justification #8: We are making this language change for clarification purposes.

• Change #9: We are changing the language in the relationship line, in page two:

• Old Language:

Relationship (if not the subject of the record): _______**Daytime Phone:__________

• New Language:

**Printed Name and Relationship: _____________ **Daytime Phone: ___________

Justification #9: We are making this language change for clarification purposes.

These revisions do not change the current burden for the form. We will implement these revisions upon OMB’s approval.