Fillable Consumer RMC LLC Packet

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Consumer RMC LLC Packet

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Instructions Page
Please ensure you review/sign both front and back of each form, as some
forms may be two-sided.
Please complete only areas that are shaded and/or marked with an ‘X’.
Please print and sign your name exactly as it appears on your Social
Security card.
When completing your address, please include your full residential address,
unabbreviated city, state, and zip code.
For more information on the SSA-1696 form, Claimant’s Appointment of
Representative, visit https://www.ssa.gov/forms/ssa-1696.html.
One of these SSA forms requires a witness signature. This witness can be
anyone 18 years of age or older. The form/witness does not have to be
notarized.
For faster processing, please return your completed forms via email to
DisabilityCoordinator@allsup.com. For a fax option, send to (618) 236-5795.
o Please note: Photographs of the forms cannot be accepted.
If you do not have access to fax or email, please cut and tape the postage-
paid shipping label below to your envelope and return via USPS.
DRC
Mailing Address
Section 1 - Claimant's Information
First Name Initial Last Name
City State ZIP/Postal Code Country - if outside the U.S.
Phone Number Alternate Phone Number (Optional)
Country/Area Code Phone Number Phone NumberCountry/Area Code
Number Holder's Information (Complete when applicable)
My claim is based on another person’s work or earnings (e.g., spouse or parent). This person’s information is different from mine.
Section 2 - Disclosure (Claimant Only)
By selecting this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release
information in relation to my pending claim(s) or asserted right(s) to designated associates who perform administrative duties
(e.g., clerks, assistants), partners, or parties under contractual arrangements for or with my representative. (The appointed
representative’s partners, associates, delegates and designees must be prepared to provide information in order to be
authenticated.)
Section 3 - Principal Representative (Claimant only – Complete when applicable)
I have appointed before, or appoint now, more than one representative. I ask SSA to make contacts or send notices to this
individual. My principal representative is:
Name
Last NameInitialFirst Name
--
Number Holder's Social Security Number
Social Security Number
- -
Claimant's Appointment of a Representative
Page 3 of 6
OMB No. 0960-0527
Form SSA-1696 (02-2020) UF
Discontinue Prior Editions
Social Security Administration
Claimant's Social Security Number Appointed Representative's Rep ID
- -
XXXXXXXXX
X
X
X
X
X
X
X
XX
X
X
V 6 5 Q Z L K B Y Y
City
Representative's Rep ID
Form SSA-1696 (02-2020) UF
Section 5 - Representative's Status, Affiliations, and Certifications (Representative Only)
Representative's Status Part A - Type of Representative (Representatives have a duty to keep their information current)
I am an attorney (SSA regulation states that an attorney is someone in good standing who has the right to practice law
before a court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a
lower Federal court of the United States.)
I am a non-attorney eligible for direct payment (SSA law requires that non-attorneys meet certain criteria to qualify for direct
payment. Refer to our website at www.ssa.gov/representation for criteria).
I am a non-attorney not eligible for direct payment.
Representative's Status Part B - Disqualification
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice law.
NoYes
I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.
NoYes
Claimant's Social Security Number Appointed Representative's Rep ID
- -
First Name Initial Last Name
Mailing Address
State ZIP/Postal Code Country - if outside the U.S.
Phone Number Alternate Phone Number (Optional)
Country/Area Code Phone Number Phone NumberCountry/Area Code
Section 4 - Representative's Information (Claimant and Representative)
Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before the appointment.
For more information about registration visit us on-line at www.socialsecurity.gov/ar, contact us at 1-800-772-1213
(TTY 1-800-325-0778), or visit your local Social Security office.
Page 4 of 6
X
V 6 5 Q Z L K B Y Y
Regina
M.
Carlton
300 Allsup Place
IL
62223
800
560-1410
V 6 5 Q Z L K B Y Y
Form SSA-1696 (02-2020) UF Page 5 of 6
I accept this appointment and certify the following:
• I understand and agree that I will comply with SSA's laws and rules on the representation of parties, including the Rules of
Conduct and Standards of Responsibility for Representatives; I will not charge, collect, or retain a fee for representational
services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or disqualified as a representative
before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or prohibited, for any reason, from practicing before the Social Security Administration.
• I am not disqualified from representing the claimant as a current or former officer or employee of the United States.
• I accept appointment as the representative for the claimant named in Section 2 of this form in connection with the claims and
asserted rights described in Section 6 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as the original.
• I declare under penalty of perjury that I have examined all of the information on this form and on all accompanying statements or
forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true
and correct to the best of my knowledge.
If I intend to seek direct payment of the authorized fee on this claim -
• I have registered for and obtained a Rep ID, and my registration information is up-to-date.
• I have provided up-to-date information on my registration concerning whether I have been suspended or prohibited from practice
before SSA or any other Federal program or agency, disbarred or suspended by a court or bar, and convicted of a violation
under Section 206 or 1631(d) of the Social Security Act.
I CERTIFY TO ALL OF THE ABOVE (Representative's Initials)
Representative's Certification
Claimant's Social Security Number Appointed Representative's Rep ID
- -
Affiliation Information
If you are representing the claimant(s) as a partner or employee of a business entity, firm or other organization you may provide
your Employer Identification Number (EIN) here, if one exists for tax purposes. This number is not your Social Security Number
(SSN). This is your employer’s tax identification number.
(Do not complete this section if you do not qualify for direct payment.)
Representative's Business Address (if different than mailing address)
Organization’s Name (Enter the full name of the business, entity, firm or organization with which you want to be affiliated while
representing this claim)
City State ZIP/Postal Code
Country - if outside the U.S.
Section 5 - Continued (Representative Only)
-
EIN
X
RMC
V 6 5 Q Z L K B Y Y
8 2
2 2 0 8 5 0 6
Allsup, LLC
300 Allsup Place
Belleville
IL
62223
Form SSA-1696 (02-2020) UF
Claimant's Social Security Number Appointed Representative's Rep ID
- -
Section 6 - Claim Type (Claimant or Representative)
I appoint the individual named in Section 4 to act as my representative in connection with my claim(s) or asserted right(s) under
Title II (RSDI), Title XVI (SSI), Title XVIII (Medicare Coverage), and Title VIII (SVB) of the Social Security Act, as presently
amended, specifically for the issues identified below: (Check all that apply)
Claim/Appeal for Retirement Benefits
Claim/Appeal for Title II Disability Benefits
Claim/Appeal for Title XVIII (Medicare), VIII (Special Veteran’s Benefits)
Continuing Disability Review (CDR)
Post-Entitlement Issue (a new issue you raise after eligibility for other benefits)
Section 7 - Fee Arrangement (Representative Only)
Check one box below:
I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to
withhold a portion of the past-due benefits to pay you the fee we may authorize. (We must authorize the fee.)
I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due
benefits, or if you do not want direct payment. You must collect any fee we may authorize on your own. (We must
authorize the fee.)
I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual. Select this
box if you certify that an entity, or a Federal, state, county, or city government agency will pay the fee and any expenses
from its funds. The claimant, auxiliary beneficiaries, or other individuals must not be liable for the fee, directly or indirectly,
in whole or in part, or any expenses. (We do not need to authorize the fee if all regulatory conditions apply.)
Section 8 - Signatures (Claimant and Representative)
Representative's Signature
Date
Date
Claimant's Signature
(E.g., benefit amount, month of entitlement, representative payee, suspension, termination, overpayment)
Page 6 of 6
Claim/Appeal for Title XVI Disability Benefits
Concurrent Title II and Title XVI Disability Benefits
I waive the right to a fee.
X
X
X
V 6 5 Q Z L K B Y Y
*Not associated with any governmental agency.
FEE AGREEMENT
Claimant: ____________________________
____________________SSN: __________________________________
I, ______________________________ (hereafter to be referred to as claimant), have appointed a representative(s) from
Allsup, LLC* to represent me in administrative proceedings in connection with my claim(s) for benefits under the
provisions of the Social Security Act.
My representative(s) and I understand that for a fee to be payable, the Social Security Administration (SSA) must approve
any fee my representative(s) charges to or collects from me for services my representative provides in proceedings before
SSA in connection with my claim(s) for benefits.
We agree that if SSA favorably decides my claim(s) for benefits, I will pay my representative(s) a fee equal to the lesser
of twenty-five percent (25%) of the past-due benefits resulting from my claim(s) or $6,000.00. We understand that the fee
is payable in full immediately upon receipt of the past-due benefits from SSA.
A) [For Title II Benefits]
We understand that Social Security past-due benefits are the total amount of money to which I [and any auxiliary
beneficiary(ies)] become entitled through the month before the month SSA effectuates a favorable administrative
determination or decision on my claim.
B) [For Title XVI Benefits]
We understand that Supplemental Security Income past-due benefits are the total amount of money for which I become
eligible through the month SSA effectuates a favorable administrative determination or decision on my claim.
C) [For Concurrent Titles II and XVI Benefits]
We understand that Social Security past-due benefits are the total amount of money to which I [and auxiliary
beneficiary(ies)] become entitled through the month before the month SSA effectuates a favorable administrative
determination or decision on my Social Security Claim and that Supplemental Security Income (SSI) past-due benefits are
the total amount of money for which I become eligible through the month SSA effectuates a favorable administrative
determination or decision on my SSI Claim. We further understand that the fee for both claims may not exceed the lesser
of $6,000.00 or 25% for the combined past-due benefits.
If a favorable allowance of my claim is made, an escrow payment is required to act as security of the authorization of a
fee. Any money in excess of the fee authorized by the Social Security Administration will be refundable to me when the
Social Security Administration approves a fee.
We have both received signed copies of this agreement.
Claimant Signature Date
Representative Date
Representative Date
X
X
X
X
X
Form SSA-827 (11-2012) ef (11-2012) Use 4-2009 and Later Editions Until Supply is Exhausted
AUTHORIZATION TO DISCLOSE INFORMATION TO
THE SOCIAL SECURITY ADMINISTRATION (SSA)
Form Approved
OMB No. 0960-0623
Page1 of 2
WHOSE Records to be Disclosed
NAME (First, Middle, Last, Suffix)
SSN
Birthday
(mm/dd/yy)
** PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW **
I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange):
OF WHAT All my medical records; also education records and other information related to my ability to
perform tasks. This includes specific permission to release:
1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s)
including , and not limited to :
Psychological, psychiatric or other mental impairment(s) (excludes "psychotherapy notes" as defined in 45 CFR 164.501)
Drug abuse, alcoholism, or other substance abuse
Sickle cell anemia
Records which may indicate the presence of a communicable or noncommunicable disease; and tests for or records of HIV/AIDS
Gene-related impairments (including genetic test results)
•
•
•
•
•
2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.
3. Copies of educational tests or evaluations, including Individualized Educational Programs, triennial assessments, psychological and
speech evaluations, and any other records that can help evaluate function; also teachers' observations and evaluations.
4. Information created within 12 months after the date this authorization is signed, as well as past information.
FROM WHOM
All medical sources (hospitals, clinics, labs,
physicians, psychologists, etc.) including
mental health, correctional, addiction
treatment, and VA health care facilities
All educational sources (schools, teachers,
records administrators, counselors, etc.)
Social workers/rehabilitation counselors
Consulting examiners used by SSA
Employers, insurance companies, workers'
compensation programs
Others who may know about my condition
(family, neighbors, friends, public officials)
•
•
•
•
•
•
TO WHOM
The Social Security Administration and to the State agency authorized to process my case (usually called "disability
determination services"), including contract copy services, and doctors or other professionals consulted during the
process. [Also, for international claims, to the U.S. Department of State Foreign Service Post.]
PURPOSE
Determining my eligibility for benefits, including looking at the combined effect of any impairments that
by themselves would not meet SSA's definition of disability; and whether I can manage such benefits.
Determining whether I am capable of managing benefits ONLY (check only if this applies)
EXPIRES WHEN
This authorization is good for 12 months from the date signed (below my signature).
I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.
I understand that there are some circumstances in which this information may be redisclosed to other parties (see page 2 for details).
I may write to SSA and my sources to revoke this authorization at any time (see page 2 for details).
SSA will give me a copy of this form if I ask; I may ask the source to allow me to inspect or get a copy of material to be disclosed.
I have read both pages of this form and agree to the disclosures above from the types of sources listed.
•
•
•
•
•
THIS BOX TO BE COMPLETED BY SSA/DDS (as needed) Additional information to identify
the subject (e.g., other names used), the specific source, or the material to be disclosed:
PLEASE SIGN USING BLUE OR BLACK INK ONLY
INDIVIDUAL authorizing disclosure
SIGN
IF not signed by subject of disclosure, specify basis for authority to sign
Parent of minor Guardian
Other personal representative
(explain)
(Parent/guardian/personal representative sign
here if two signatures required by State law)
Date Signed
Phone Number (with area code )
Street Address
City State ZIP
WITNESS I know the person signing this form or am satisfied of this person's identity:
SIGN
Phone Number (or Address)
IF needed, second witness sign here (e.g., if signed with "X" above)
SIGN
Phone Number (or Address)
This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and
other information under P.L. 104-191 ("HIPAA"); 45 CFR parts 160 and 164; 42 U.S. Code section 290dd-2; 42 CFR part 2; 38 U.S. Code section
7332; 38 CFR 1.475; 20 U.S. Code section 1232g ("FERPA"); 34 CFR parts 99 and 300; and State law.
X
X
X
X
X
X
X
X
X
X
X
X
Page 2 of 2
Explanation of Form SSA-827,
"Authorization to Disclose Information to the Social Security Administration (SSA)"
We need your written authorization to help get the information required to process your claim, and to determine your capability of
managing benefits. Laws and regulations require that sources of personal information have a signed authorization before releasing
it to us. Also, laws require specific authorization for the release of information about certain conditions and from educational
sources.
You can provide this authorization by signing a form SSA-827. Federal law permits sources with information about you to release
that information if you sign a single authorization to release all your information from all your possible sources. We will make
copies of it for each source. A covered entity (that is, a source of medical information about you) may not condition treatment,
payment, enrollment, or eligibility for benefits on whether you sign this authorization form. A few States, and some individual
sources of information, require that the authorization specifically name the source that you authorize to release personal
information. In those cases, we may ask you to sign one authorization for each source and we may contact you again if we need
you to sign more authorizations.
You have the right to revoke this authorization at any time, except to the extent a source of information has already relied on it to
take an action. To revoke, send a written statement to any Social Security Office. If you do, also send a copy directly to any of
your sources that you no longer wish to disclose information about you; SSA can tell you if we identified any sources you didn't
tell us about. SSA may use information disclosed prior to revocation to decide your claim.
It is SSA's policy to provide service to people with limited English proficiency in their native language or preferred mode of
communication consistent with Executive Order 13166 (August 11, 2000) and the Individuals with Disabilities Education Act.
SSA makes every reasonable effort to ensure that the information in the SSA-827 is provided to you in your native or preferred
language.
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 233(d)(5)(A), 1614(a)(3)(H)(i), 1631(d)(l) and 1631(e)(l)(A) of the Social Security Act as amended, [42 U.S.C. 405(a), 433(d)
(5)(A), 1382c(a)(3)(H)(i), 1383(d)(l) and 1383(e)(l)(A)] authorize us to collect this information. We will use the information you provide to help
us determine your eligibility, or continuing eligibility for benefits, and your ability to manage any benefits received. The information you
provide is voluntary. However, failure to provide the requested information may prevent us from making an accurate and timely decision on
your claim, and could result in denial or loss of benefits.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above. However, we may use
it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency
in accordance with approved routine uses, including but not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office, General Services Administration, National Archives Records
Administration, and the Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of our programs (e.g., to the U.S. Census Bureau and to private entities under contract
with us).
We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept
by other Federal, State, or local government agencies. We use the information from these programs to establish or verify a person’s eligibility
for Federally funded or administered benefit programs and for repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses of the information you gave us is available in our Privacy Act Systems of Records Notices entitled, Claims
Folder System, 60-0089; Master Beneficiary Record, 60-0090; Supplemental Security Income record and Special Veterans benefits, 60-0103;
and Electronic Disability (eDIB) Claims File, 60-0340. The notices, additional information regarding this form, and information regarding our
systems and programs, are available on-line at www.socialsecurity.gov or at any 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 10 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 Social Security at 1-800-772-1213 (TTY 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.
Form SSA-827 (11-2012) ef (11-2012)
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Consumer RMC LLC Packet

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Completed 16 July 2020

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