Form SSA-3288 Consent for Release of Information

Social Security Administration

Consent for Release of Information
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). You may complete this form to release only the minor’s non-medical
records if you are the natural or adoptive parent or legal guardian, acting on behalf of a minor child. We may charge a fee for providing
the information if you are requesting the information for a purpose unrelated to the administration of a program under the Social
Security Act.
NOTE: Do not use this form to:
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Request the release of a minor child’s medical records. 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.
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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 of 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, in accordance with 5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the information provided 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 payments or
delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and other Social Security programs are available from our
Internet website at 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.

SSA-3288

Social Security Administration

Consent for Release of Information
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
______________________________________

________________

________________________

*Full Name

*Date of Birth

*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: ____________________________________________
We may charge a fee to release information for non-program purposes.

____________________________________________________________________________________________
____________________________________________________________________________________________

*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.

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
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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’s medical records, do not use this form. Instead, contact your local Social Security office.

 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.)

__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

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.

*Signature: __________________________________________________ *Date: _____________________
**Address: ___________________________________________________**Daytime Phone: ___________
Relationship (if not the subject of the record): ____________________

**Daytime Phone: _________________

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.
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

SSA-3288