Official Federal Forms > Social Security Administration
Consent For Release Of Information SSA-3288 - Official Federal Forms
| Consent For Release Of Information Form. This is a national form and can be used in Social Security Administration . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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. 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. How to Complete This Form 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) American LegalNet, Inc. www.FormsWorkflow.com Social Security Administration Form Approved OMB No. 0960-0566 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: Date: Form SSA-3288 (5-2007) EF (5-2007) (Show signatures, names, and addresses of two people if signed by mark.) Relationship: American LegalNet, Inc. www.FormsWorkflow.com
|
|||||||
