Fillable Ssa-827 Authorization to Disclose information to Social Security Administration

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Ssa-827 Authorization to Disclose information to Social Security Administration

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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
u
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)
u
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
u
Phone Number (or Address)
IF needed, second witness sign here (e.g., if signed with "X" above)
SIGN
u
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.
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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Ssa-827 Authorization to Disclose information to Social Security Administration

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Completed 16 November 2019

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