WHOSE Records to be Disclosed
OMB No. 0960-0623
NAME (First, Middle, Last, Suffix)
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 CFR 164.501)
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 of 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.
Additional information to identify
THIS BOX TO BE COMPLETED BY SSA/DDS (as needed)
All medical sources (hospitals, clinics, labs,
the subject (e.g., other names used), the specific source, or the material to be disclosed:
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'
Others who may know about my condition
(family, neighbors, friends, public officials)
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.]
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.
Determining whether I am capable of managing benefits ONLY (check only if this applies)
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 for details).
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.
IF not signed by subject of disclosure, specify basis for authority to sign
PLEASE SIGN USING BLUE OR BLACK INK ONLY
Parent of minor
Other personal representative
(Parent/guardian/personal representative sign
here if two signatures required by State law)
Phone Number (with area code )
I know the person signing this form or am satisfied of this person's identity:
IF needed, second witness sign here (e.g., if signed with "X" above)
Phone Number (or Address)
Phone Number (or Address)
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 (11-2012) ef (11-2012) Use 4-2009 and Later Editions Until Supply is Exhausted
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