Form Ssa-3288 - Social Security Administration - Consent For Release Of Information Form

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Form Approved
Social Security Administration
OMB No. 0960-0566
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 minor's 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
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
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
person's eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these
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.
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 SSA's website at
. Offices are also listed under U.S. Government agencies in your telephone directory or you may call
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-3288 (07-2010) EF (07-2010) Destroy Prior Editions


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