Authorization Form To Disclose Information To The Social Security Administration (Ssa) Page 2
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1
2Explanation 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.
IMPORTANT INFORMATION, INCLUDING NOTICE REQUIRED BY THE PRIVACY ACT
All personal information collected by SSA is protected by the Privacy Act of 1974. Once medical information is disclosed to
SSA, it is no longer protected by the health information privacy provisions of 45 CFR part 164 (mandated by the Health Insurance
Portability and Accountability Act (HIPAA)). SSA retains personal information in strict adherence to the retention schedules
established and maintained in conjunction with the National Archives and Records Administration. At the end of a record's useful
life cycle, it is destroyed in accordance with the privacy provisions, as specified in 36 CFR part 1228.
SSA is authorized to collect the information on form SSA-827 by sections 205(a), 223(d)(5)(A), 1614(a)(3)(H)(i), 1631(d)(1) and
1631 (e)(1)(A) of the Social Security Act. We use the information obtained with this form to determine your eligibility, or
continuing eligibility, for benefits, and your ability to manage any benefits received. This use usually includes review of the
information by the State agency processing your case and quality control people in SSA. In some cases, your information may
also be reviewed by SSA personnel that process your appeal of a decision, or by investigators to resolve allegations of fraud or
abuse, and may be used in any related administrative, civil, or criminal proceedings.
Signing this form is voluntary, but failing to sign it, or revoking it before we receive necessary information, could prevent an
accurate or timely decision on your claim, and could result in denial or loss of benefits. Although the information we obtain with
this form is almost never used for any purpose other than those stated above, the information may be disclosed by SSA without
your consent if authorized by Federal laws such as the Privacy Act and the Social Security Act. For example, SSA may disclose
information:
1. To enable a third party (e.g., consulting physicians) or other government agency to assist SSA to establish rights to
Social Security benefits and/or coverage;
2. Pursuant to law authorizing the release of information from Social Security records (e.g., to the Inspector General, to
Federal or State benefit agencies or auditors, or to the Department of Veterans Affairs(VA));
3. For statistical research and audit activities necessary to ensure the integrity and improvement of the Social Security
programs (e.g., to the Bureau of the Census and private concerns under contract with SSA).
SSA will not redisclose without proper prior written consent information: (1) relating to alcohol and/or drug abuse as covered in
42 CFR part 2, or (2) from educational records for a minor obtained under 34 CFR part 99 (Family Educational Rights and
Privacy Act (FERPA)), or (3) regarding mental health, developmental disability, AIDS or HIV.
We may also use the information you give us when we match records by computer. Matching programs compare our records
with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that
a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about possible reasons why information you provide us may be used or given out are available upon request from
any Social Security Office.
PAPERWORK REDUCTION ACT
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 IN THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is 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 (4-2009) ef (04-2009)
Page 2 of 2
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