Form Ssa-3288 - Consent For Release Of Information
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1Social Security Administration
Form Approved
OMB No. 0960-0566
Consent for Release of Information
_______________________________________________________________________________________________
You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a
required field).
TO: Social Security Administration
_________________________________
(Name)
_________________________________
#/##/####
_________________________________
###-##-####
*My Full Name
*My Date of Birth
*My Social Security Number
(MM/DD/YYYY)
I authorize the Social Security Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION:
*ADDRESS OF PERSON OR ORGANIZATION::
Law Office of Beverly Manley & Associates, P.C.
_________________________________________________
_________________________________________________
P.O. Box 450534 Atlanta, GA 31145-0534
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
*I want this information released because: There is a need to establish the date of my SSDI entitlement, my Medicare
_________________________________________________________________
We may charge a fee to release information for non-program purposes.
status, date of entitlement for Medicare, and basis for entitlement (disability or age). Is there a representative payee designated
_______________________________________________________________________________________________
to receive benefits on my behalf? If so, provide representative payee name.
_______________________________________________________________________________________________
*Please release the following information selected from the list below:
You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all
records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.
□
1.
Social Security Number
□
2.
Current monthy Social Security benefit amount
□
3.
Current monthly Supplemental Security Income payment amount
□
4.
My benefit or payment amounts from date ___________ to date ___________
□
5.
My Medicare entitlement from date ___________ to date ___________
□
6.
Medical records from my claims folder(s) from date ___________ to date ___________
If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security
office.
□
7.
Complete medical records from my claims folder(s)
□
X Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application,
8.
determination or questionnaire)
___________________________________________________________________________________________
Social Security entitlement status, date of entitlement or date of application if still pending, basis for entitlement, Medicare
___________________________________________________________________________________________
status, date of entitlement for Medicare. If not a current Social Security recipient, include number of quarters paid in.
I am the individual, to whom the requested information or 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 (28 CFR § 16.41(d)(2004)) that I have
examined all the information on this form, and 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 seeks or obtain access to records about
another person under false pretenses is punishable by a fine of up to $5,000. I also understand that I must pay all
applicable fees for requesting information for a non-program-related purpose.
*Signature: _________________________________________________________
*Date: _____________________________
*Address: _____________________________________________________________________________________________
*Relationship (If not the subject of the record): __________________________
*Daytime Phone: ___________________
Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing
who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the
_______________________________________________________________________________________________
signature line above.
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1.Signature of witness
2.Signature of witness
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_______________________________________________________________________________________________
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Address(Number and street,City,State, and Zip Code)
Address(Number and street,City,State, and Zip Code)
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_______________________________________________________________________________________________
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Form SSA-3288 (07-2013) EF (07-2013)
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