Fillable BPQY-POC-Release-Form-2 Consent for Release of Information

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BPQY-POC-Release-Form-2 Consent for Release of Information

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Form SSA-3288 (11-2016) uf
Destroy Prior Editions
Social Security Administration
Consent for Release of Information
Form Approved
OMB No. 0960-0566
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 child, you may complete this form to release only the minor's non-medical records. We may charge a
fee for providing information 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
.
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 "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 the 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 the legal guardian acting on behalf of a minor child 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.
PRIVACY ACT STATEMENT
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, the Privacy Act (5 U.S.C. § 552a(b)) permits us to disclose the information you provide 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 incorrect
payments or overpayments under these programs. Additional information regarding this form, routine uses of information, and
other Social Security programs is available on our Internet website, 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.
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).
TO: Social Security Administration
*My Full Name
*My Date of Birth
(MM/DD/YYYY)
*My Social Security Number
I authorize the Social Security Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:
*I want this information released because:
*Please release the following information selected from the list below:
Check at least one box. We will not disclose records unless you include date ranges where applicable.
Verification of Social Security Number
If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social
Security office.
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 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 I must pay all applicable fees for requesting information for a non-program-related purpose.
Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing
who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the
signature line above.
Form SSA-3288 (11-2016) uf
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We may charge a fee to release information for non-program purposes.
Form Approved
OMB No. 0960-0566
Consent for Release of Information
Social Security Administration
Current monthly Social Security benefit amount
Current monthly Supplemental Security Income payment amount
My benefit or payment amounts from date to date
My Medicare entitlement from date to date
Medical records from my claims folder(s) from date to date
Complete medical records from my claims folder(s)
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.)
*Signature:
**Address:
*Date:
Relationship (if not the subject of the record):
**Daytime Phone:
1.Signature of witness
2.Signature of witness
Address(Number and street,City,State, and Zip Code)
Address(Number and street,City,State, and Zip Code)
**Daytime Phone:
I am planning to return to work. I authorize this requestor
to receive information to provide me with program related return to work assistance.
I authorize release of the records for 1 year beginning with the date I signed this form.
Beneficiary's cash benefits, health insurance, medical review dates, representation, SSDI
and SSI work activity and earnings. All employment supports data on SSA's records.
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BPQY-POC-Release-Form-2 Consent for Release of Information

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Completed 15 February 2020

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