Form Ssa-827-Inst - Instructions For Completing The Ssa-827 printable pdf download

INSTRUCTIONS FOR COMPLETING THE SSA-827

THESE INSTRUCTIONS IN (INSERT LANGUAGE) PROVIDE THE WORDING ON THE ENGLISH VERSION OF THE SSA-827 FORM. YOU

MUST SIGN, DATE, AND RETURN THE ENGLISH VERSION OF THE SSA-827 TO YOUR LOCAL SOCIAL SECURITY OFFICE TO HAVE

YOUR DISABILITY CLAIM PROCESSED.

WHOSE Records to be Disclosed - Please provide your first, middle, last name and suffix (if any), your social security number, and your

birthdate.

AUTHORIZATION TO DISCLOSE INFORMATION TO THE SOCIAL SECURITY ADMINISTRATION (SSA)

**PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW**

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange):

OF WHAT

All my medical records; also education records and other information related to my ability to perform tasks. This

includes specific permission to release :

1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s)

including, and not limited to:

•

Psychological, psychiatric or other mental impairment(s) (excludes "psychotherapy notes" as defined in 45 CFR164.501)

•

Drug abuse, alcoholism, or other substance abuse

•

Sickle cell anemia

•

Records which may indicate the presence of a communicable or noncommunicable disease; and tests for or records HIV/AIDS

•

Gene-related impairments (including genetic test results)

2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects

my ability to work.

3. Copies of educational tests or evaluations, including Individualized Educational Programs, triennial assessments,

psychological and speech evaluations, and any other records that can help evaluate function; also teachers'

observations and evaluations.

4. Information created within 12 months after the date this authorization is signed, as well as past information.

FROM WHOM

•

All medical sources (hospitals, clinics, labs, physicians, psychologists, etc.) including mental health, correctional, addiction

treatment, and VA health care facilities

•

All educational sources (schools, teachers, records administrators, counselors, etc.)

•

Social workers/rehabilitation counselors

•

Consulting examiners used by SSA

•

Employers, insurance companies, workers' compensation programs

•

Others who may know about my condition (family, neighbors, friends, public officials)

TO WHOM

The Social Security Administration and to the State agency authorized to process my case (usually called "disability

determination services"), including contract copy services, and doctors or other professionals consulted during the

process. [Also, for international claims, to the U.S. Department of State Foreign Service Post.]

PURPOSE

Determining my eligibility for benefits, including looking at the combined effect of any impairments that by themselves would not

meet SSA's definition of disability; and whether I can manage such benefits.

Check the box to the left on the English SSA-827 if we are ONLY determining whether you are capable of managing benefits.

EXPIRES WHEN This authorization is good for 12 months from the date signed (below my signature).

•

I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.

•

I understand that there are some circumstances in which this information may be redisclosed to other parties

(see page 2 for details).

•

I may write to SSA and my sources to revoke this authorization at any time (see page 2 EXPLANATION OF FORM SSA-827). SSA will

give me a copy of this form if I ask; I may ask the source to allow me to inspect or get a copy of material to be disclosed.

•

I have read both pages of this form and agree to the disclosures above from the types of sources listed.

PLEASE SIGN USING BLUE OR BLACK INK ONLY.

IF not signed by subject of disclosure, specify basis for authority

to sign.

INDIVIDUAL authorizing disclosure

Check the appropriate box on the English SSA-827 to indicate

whether the person signing is the parent of a minor, guardian, or other

SIGN The individual must sign and date this authorization, and

personal representative (explain). Sign the English SSA-827 in the

provide his or her telephone number with area code, street

space provided if two signatures are required by State law.

address, city, state and zip code.

WITNESS: In this section of the English SSA-827, one who knows the person signing the form should sign as a witness and

provide his or her phone number or address. There is space for a second witness if needed.

This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and

other information under P.L. 104-191 ("HIPAA"); 45 CFR parts 160 and 164; 42 U.S. Code section 290dd-2; 42 CFR part 2; 38 U.S. Code

section 7332; 38 CFR 1.475; 20 U.S. Code section 1232g ("FERPA"); 34 CFR parts 99 and 300; and State law.

Form SSA-827-INST (01-2013)

Form Ssa-827-Inst - Instructions For Completing The Ssa-827

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