Privacy Release Form For Social Security/ssi Casework
ADVERTISEMENT
1U.S. Representative Mike Rogers
rd
3
District Alabama
Privacy Release Form for Social Security/SSI Casework
Please print or type:
Part 1.
Information about You or the Person Experiencing the Problem
Full Name: (last) _________________________________________ (first) ____________________________________(MI) __________
Street Address: ____________________________________________ City: ______________________ State: _____Zip: ___________
Phone: __________________ Cell Phone: ________________ SS Number:________________________Date of Birth: ______________
Part 2.
Type of Problem You Are Experiencing – Check the box that applies
SSI Claim
SS Disability Claim
Retirement
Payment Problem
Other
Part 3.
Disability
When was the original claim filed?
__________________________
Where?: _________________________________
Has a decision been issued?
yes
no When? _____________ What was the decision?
Approved
Denied
If denied, did you request a hearing?
yes
no When? _____________
Have you had a hearing?
yes
no When? _____________
What hearing office has the claim?
Atlanta
Birmingham
Montgomery
Has a decision been issued?
yes
no When? _____________ What was the decision?
Approved
Denied
If the Judge denied your claim did you appeal?
yes
no
List your medical problems:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Are you disabled because of a work related injury?
yes
no
Have you received periodic worker’s compensation or a worker’s compensation settlement?
yes
no
Are you waiting for a worker’s compensation settlement?
yes
no
Part 4. What You Need to Attach to This Form
•
Attach a letter explaining the problem you are experiencing and how you would like for me to try to assist
you.
•
Attach a copy the latest application or appeal you filed with the Social Security Administration.
•
Attach any pertinent correspondence you have received from the Social Security Administration.
•
If you are disabled from a work related injury, attach a statement form the worker’s compensation company
giving the dates and amounts of the periodic payments you received
•
If you are disabled from a work related injury, attach a copy of the settlement.
Pursuant to the Privacy Act of 1974, I authorized the Social Security Administration to release personal information
to Congressman Mike Rogers and/or his staff in order for him to assist me with the above matter.
Signature: _____________________________________________
Date: _______/_____/________
If you live in: Calhoun, Cherokee, Clay,
If you live in: Chambers, Lee, Russell,
If you live in: Coosa, Macon,
Cleburne, Randolph, or Talladega County
or Tallapoosa County
or Montgomery County
Mail to:
Mail to:
Mail to:
Congressman Mike Rogers
Congressman Mike Rogers
Congressman Mike Rogers
1129 Noble Street, Room 104
1819 Pepperell Parkway, Ste 203
7550 Halcyon Summit Drive
Anniston, AL 36201
Opelika, AL 36801
Montgomery, AL 36117
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal