Addendum to the Supporting Statement for SSA-3288
Privacy and Disclosure of Official Records and Information;
Availability of Information and Records to the Public;
20 CFR 401 and 402
OMB No. 0960-0566
Revision to the Collection Instrument
Change 1: We are changing the language in page one, “How to Complete this Form.”
Old Language:
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 information.
Check the box next to the type(s) of information you want us to release including the date ranges, where applicable.
You, the parent or legal guardian acting on behalf of a minor 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.
New Language:
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 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 legal guardian acting on behalf of a minor 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.
Justification 1: We are making this language change for clarification purposes.
Change 2: We are changing the language in page two, “Consent for Release of Information.”
Old Language:
You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a required field).
New Language:
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.)
Justification 2: We are making this language change for clarification purposes.
Change 3: We are changing the language in “Please release the following information selected from the list below.”
Old Language:
You must specify the records you are requesting by checking at least one box. We will
not honor a request for “any and all records” or “my entire file.” Also, we will not
disclose records you include the applicable date ranges where requested.
New Language:
Check at least one box. We will not disclose records unless you include date ranges where applicable.
Justification 3: We are making this language change for clarification purposes.
Change 4: We are changing the language in “Please release the following information selected from the list below, checkboxes #1 and #8.”
Old Language:
Social Security Number
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__________
If you want us to release a minor child’s medical records, do not use this form. Instead, contact your local Social Security office.
Complete medical records from my claims folder(s)
8. Other record(s) from my file (you must specify the records you are requesting,
e.g. doctor report, application, determination or questionnaire)
________________________________________________________________________
________________________________________________________________________
New Language:
Verification of Social Security Number
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__________
If you want us to release a minor child’s medical records, do not use this form. Instead, contact your local Social Security office.
Complete medical records from my claims folder(s)
8. 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.)
________________________________________________________________________
Justification 4: We are making this language change for clarification purposes.
Change 5: We are changing the language in the attestation statement.
Old Language:
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 any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeks or obtain 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.
New Language:
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 seeks or obtain 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.
Justification 5: We are making this language change for clarification purposes.
Change 6: We are changing the language in the address line.
Old Language:
*Address:_______________________________________________________________
New Language:
**Address: ____________________________________**Daytime Phone: ____________
Justification 6: We are making this language change for clarification purposes.
Change 7: We are changing the language in the relationship line.
Old Language:
Relationship (if not the subject of the record): _________*Daytime Phone: _________
New Language:
Relationship (if not the subject of the record): _______**Daytime Phone:__________
Justification 7: We are making this language change for clarification purposes.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | ADDENDUM TO SUPPORTING STATEMENT |
| Author | Naomi |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |