Social Security Administration Consent For Release Of Information Page 2
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1
2Form Approved
OMB No. 0960-0566
Social Security Administration
Consent for Release of Information
Please read these instructions carefully before completing this form.
When to Use
Complete this form only if you want the Social Security Administration to
give information or records about you to an individual or group (for
This Form
example, a doctor, or an insurance company).
Natural or adoptive parents or a legal guardian, acting on behalf of a
minor, who want us to release the minor's:
• nonmedical records, should use this form.
• medical records, should not use this form, but should contact us.
Note: Do not use this form to request information about your earnings or
employment history. To do this, complete Form SSA-7050-F4. You can get
this form at any Social Security office.
This consent form must be completed and signed only by:
• the person to whom the information or record applies, or
How to
• the parent or legal guardian of a minor to whom the nonmedical
Complete
information applies, or
This Form
• the legal guardian of a legally incompetent adult to whom the information
applies.
To complete this form:
• Fill in the name, date of birth, and Social Security Number of the person to
whom the information applies.
• Fill in the name and address of the individual or group to which we will
send the information.
• Fill in the reason you are requesting the information.
• Check the type(s) of information you want us to release.
• Sign and date the form. If you are not the person whose record we will
release, please state your relationship to that person.
PAPERWORK REDUCTION ACT: Paperwork Reduction Act Statement: This information collection meets the clearance
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. The office is listed under U S. Government agencies in your telephone
directory or you may call 1-800-772-1213 for the address. You may send comments on our estimate of' the time needed to complete the
form to: SSA. 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not
the completed form.
Form SSA-3288 (3-2005) EF (3-2005)
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