SSA-3288-OP1: (Webform Application) (current)

Creating Advanced Streamlined Electronic Services for
Constituents (CASES) Act
Release 1
Webform Application
Screen Package
December 21st, 2022

Contents
Application Landing Page: ...................................................................................................................................................... 3
Authentication:....................................................................................................................................................................... 3
Terms of Service: .................................................................................................................................................................... 6
Privacy Act Statement: ........................................................................................................................................................... 7
Instructions: ............................................................................................................................................................................ 8
Information Required for Identity-Proofing and Authentication: ........................................................................................ 9
Description of Requested Records: ..................................................................................................................................... 10
Add Recipients:..................................................................................................................................................................... 17
Release Reason:.................................................................................................................................................................... 19
Review and Submit: ............................................................................................................................................................. 20
Confirmation: ....................................................................................................................................................................... 22
Appendix:.............................................................................................................................................................................. 23

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Application Landing Page:

Authentication:

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User is brought to the user login screen. User enters username and password for eAccess legacy login and clicks
the “Sign in” button.

User is brought to a screen where user verifies their cell phone number and selects the radio button for “Yes, it
is correct. Please provide a security code now.”

User enters the security code received and clicks the “Submit Security Code” button.

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User selects the “I agree to the Terms of Service” checkbox and clicks the “Next” button.

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Terms of Service:

Upon successful authentication, the user will be presented with the Terms of Service for the online Form SSA3288-OP1. The user must select the “I agree to the Terms of Service” button to continue.

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Privacy Act Statement:

After agreeing to the Terms of Service, the user is presented with the Privacy Act statement. The user must click on
the “Next” button to continue.

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Instructions:

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Information Required for Identity-Proofing and Authentication:

Identifying information for the authenticated individual is displayed to the user. If this information is incorrect, the
user must contact SSA to update the information. The user clicks the “Next” button to continue.

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Description of Requested Records:

The user will have the option to select and add multiple record types from the drop-down menu by selecting the
record type and clicking the “Add Record” button. The user must select at least one record type.

Records available for the user to add include the records listed above.

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Users must specify a date range when adding the “Social Security benefit amounts” record type.

Users must specify a date range when adding the “Supplemental Security Income payment amounts” record type.

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Users must specify a date range when adding the “Medicare entitlement” record type.

Users must select either “Complete Medical Records from my claims folder(s)” or “Medical records from my claims
folder(s)” for a specific period. If choosing the latter, the user is required to provide a date range.

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Users must specify a date range and select a benefit type (Retirement, Social Security Disability or Supplemental
Security Income) from the drop down when adding the “application for benefits” record type.

Users must specify a date range and select a benefit type (Retirement, Social Security Disability or Supplemental
Security Income) from the drop down when adding the “award notice” record type.

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Users must specify a date range and select a benefit type (Retirement, Social Security Disability or Supplemental
Security Income) from the drop down when adding the “denial notice” record type.

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Users must specify a date range and select a benefit type (Retirement, Social Security Disability or Supplemental
Security Income) from the drop down when adding the “appeal request” record type.

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After the user has selected the record types they are requesting, they can either remove them from the request,
edit them or proceed by clicking the “Next” button.

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Add Recipients:

The user must add at least one recipient for the requested records using the “Add Recipient” button. The
recipient(s) can be either an organization and/or a person. The form allows a maximum of three recipients.
Add Person

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Add Organization

The user can remove or edit recipients after adding them or continue by clicking on the “Next” button.

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Release Reason:

The user must select one of four reasons for requesting release of their records.

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Review and Submit:

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On the Review and Submit page, the user can review and update any of the information they have input so far, as well
as view and print or save an unsigned version of the form (see appendix item #1). Once they are ready to submit the
request, they can acknowledge the eSignature statement by checking the “signature” check box and sign the document
by typing in their name. Providing a phone number is optional.

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Confirmation:

Upon successful submission, the user receives a confirmation message and has an opportunity to open the signed form
in a new web browser.

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From the new window, the user can choose to print, save, or view and close the form. The downloaded form will include
an eSignature audit page with the details of the signature (see Appendix Item #3).

Appendix:
1. PDF preview of the form before submitting

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2. PDF version of the signed form

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3.

eSignature audit page (screenshot)

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