Form Ssa-3288 - Social Security Administration - Consent For Release Of Information Form Page 2
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Form Approved
Social Security Administration
OMB No. 0960-0566
TO: Social Security Administration
*Name
*Date of Birth
*Social Security Number
I authorize the Social Security Administration to release information or records about me to:
*ADDRESS
*NAME
*I want this information released because:
T
*Please release the following information selected from the list below:
Social Security Number
Current monthly Social Security benefit amount
Current monthly Supplemental Security Income payment amount
My benefit/payment amounts from _______________ to __________________
My Medicare entitlement from _______________ to __________________
Medical records from my claims folder(s) from _______________ to __________________
Complete medical records from my claims folder(s)
Other record(s) from my file (e.g. applications, questionnaires, consultative examination reports,
determinations, etc.)
I am the individual to whom the requested information/record applies, or the parent or legal guardian of a minor, or
the legal guardian of a legally incompetent adult. I declare under penalty of perjury in accordance with 28 C.F.R. §
16.41(d)(2004) that I have examined all the information on this form, and on any accompanying statements or forms,
and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeking or
obtaining access to records about another person under false pretenses is punishable by a fine of up to $5,000. I also
understand that any applicable fees must be paid by me.
*Signature:
*Date:
Relationship (if not the individual):
*Daytime Phone:
Form SSA-3288 (07-2010) EF (07-2010)
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