Form Ssa-3288 - Social Security Administration Consent For Release Of Information
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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). If you are the natural or adoptive parent or legal guardian, acting
on behalf of a minor, you may complete this form to release only the minors non-medical records. If you are requesting information for
a purpose not directly related to the administration of any program under the Social Security Act, a fee may be charged.
NOTE: Do not use this form to:
•
Request us to release the medical records of a minor. Instead, contact your local office by calling 1-800-772-1213 (TTY-1-800-
325-0778), or
•
Request information about your earnings or employment history. Instead, complete form SSA-7050-F4 at any Social Security
office or online at
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 “all records” or the “entire file.” You must specify the information you are requesting and you must sign and date
this form.
•
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 information applies.
•
Fill in the name and address of the individual (or organization) to whom you want us to release your information.
•
Indicate the reason you are requesting us to disclose the information.
•
Check the box(es) next to the type(s) of information you want us to release including the date ranges, if applicable.
•
You, the parent or legal guardian acting on behalf of a minor, or the legal guardian of a legally incompetent adult, must sign and
date this form and provide a daytime phone number where you can be reached.
•
If you are not the person whose information is requested, 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. The information
you provide will be used to respond to your request for SSA records information or process your request when we 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. Information from these matching programs can be used to
establish or verify a persons 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 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 SSAs website at
. 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.
Form SSA-3288 (07-2010) EF (07-2010)
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