RETAIN SSA Authori RETAIN SSA Authorization of Disclosure Form

Form Approved

OMB No. xxxx-xxxx

WHOSE Records to be Disclosed

NAME (First, Middle, Last, Suffix):

SSN:

DOB:

M

M

D

D

Y

Y

AUTHORIZATION FOR DISCLOSURE BY THE SOCIAL SECURITY ADMINISTRATION (SSA)

CONSENT FOR RELEASE OF RETAIN STUDY INFORMATION **PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW**

I voluntarily authorize and request disclosure of my RETAIN study group status by SSA to the below recipient. I understand the information I provide at enrollment will be used by the SSA and SSA’s contractor, Mathematica Policy Research, to assign me to a RETAIN study group.

I understand:

• Unless expressly revoked, this authorization is valid for the duration of the RETAIN study.

• I may write to SSA to revoke this authorization at any time. (To revoke, send a written statement to Social Security Administration, 6401 Security Blvd, Baltimore, MD 21235-6401, Attn: Jackson Costa.)

• This authorization differs from any consent I sign to participate in the RETAIN study, and that SSA is only responsible for assignment of my study group and conducting an evaluation of the study.

• SSA will give me a copy of this form if I ask.

• My signature on this form indicates that I have read both pages of this form and agree to SSA’s disclosure of my RETAIN study group status to:

**RECIPIENT **RECIPIENT ADDRESS

___________________________________ ____________________________________

PLEASE SIGN USING BLUE OR BLACK INK ONLY. INDIVIDUAL authorizing disclosure SIGN		If you are not the individual to whom the requested information pertains, state your relationship to that person (e.g., parent or legal guardian). We may require proof of relationship.
►		►
Date Signed:	_______ / _______ / __________
Phone Number (with area code):	( ) __ __ __ - __ __ __ __
Mailing address: Street / Apartment #	City		State	Zip __ __ __ __ __

Privacy Act Statement
Collection and Use of Personal Information

Section 1110 of the Social Security Act, as amended, allows us to request this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information will prevent you from participating in the RETAIN demonstration project.

We will use the information you provide for the RETAIN project. We may also share your information for the following purposes, called routine uses:

• To a third party organization under contract to the Social Security Administration for the performance of project management activities directly related to this system of records; and

• To a State vocational rehabilitation agency in the State in which the disabled individual resides, for the purpose of assisting the agency in providing rehabilitation counseling and service to the individual that are necessary in carrying out the demonstrations and experiments.

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 Notice (SORN) 60-0218, entitled Disability Insurance and Supplemental Security Income Demonstration Projects and Experiments System, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1836. Additional information, and a full listing of all our SORNs, are available on our website at www.ssa.gov/privacy/.

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 the questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is ; expiration date. We estimate that it will take about 5 minutes to read the instructions and sign the consent. You may send comments about our time estimate to: Social Security Administration, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

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