Form Ssa-827 - Authorization To Disclose Information To The Social Security Administration (Ssa) Page 2
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2Explanation of Form SSA-827,
"Authorization to Disclose Information to the Social Security Administration (SSA)"
We need your written authorization to help get the information required to process your claim, and to determine your capability of
managing benefits. Laws and regulations require that sources of personal information have a signed authorization before releasing
it to us. Also, laws require specific authorization for the release of information about certain conditions and from educational
sources.
You can provide this authorization by signing a form SSA-827. Federal law permits sources with information about you to release
that information if you sign a single authorization to release all your information from all your possible sources. We will make
copies of it for each source. A covered entity (that is, a source of medical information about you) may not condition treatment,
payment, enrollment, or eligibility for benefits on whether you sign this authorization form. A few States, and some individual
sources of information, require that the authorization specifically name the source that you authorize to release personal
information. In those cases, we may ask you to sign one authorization for each source and we may contact you again if we need
you to sign more authorizations.
You have the right to revoke this authorization at any time, except to the extent a source of information has already relied on it to
take an action. To revoke, send a written statement to any Social Security Office. If you do, also send a copy directly to any of
your sources that you no longer wish to disclose information about you; SSA can tell you if we identified any sources you didn't
tell us about. SSA may use information disclosed prior to revocation to decide your claim.
It is SSA's policy to provide service to people with limited English proficiency in their native language or preferred mode of
communication consistent with Executive Order 13166 (August 11, 2000) and the Individuals with Disabilities Education Act.
SSA makes every reasonable effort to ensure that the information in the SSA-827 is provided to you in your native or preferred
language.
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 233(d)(5)(A), 1614(a)(3)(H)(i), 1631(d)(l) and 1631(e)(l)(A) of the Social Security Act as amended, [42 U.S.C. 405(a), 433(d)
(5)(A), 1382c(a)(3)(H)(i), 1383(d)(l) and 1383(e)(l)(A)] authorize us to collect this information. We will use the information you provide to help
us determine your eligibility, or continuing eligibility for benefits, and your ability to manage any benefits received. The information you
provide is voluntary. However, failure to provide the requested information may prevent us from making an accurate and timely decision on
your claim, and could result in denial or loss of benefits.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above. However, we may use
it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency
in accordance with approved routine uses, including but not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office, General Services Administration, National Archives Records
Administration, and the Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of our programs (e.g., to the U.S. Census Bureau and to private entities under contract
with us).
We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept
by other Federal, State, or local government agencies. We use the information from these programs to establish or verify a person’s eligibility
for Federally funded or administered benefit programs and for repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses of the information you gave us is available in our Privacy Act Systems of Records Notices entitled, Claims
Folder System, 60-0089; Master Beneficiary Record, 60-0090; Supplemental Security Income record and Special Veterans benefits, 60-0103;
and Electronic Disability (eDIB) Claims File, 60-0340. The notices, additional information regarding this form, and information regarding our
systems and programs, are available on-line at
or at any Social Security office.
Paperwork Reduction Act Statement - 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 10 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
Offices are also listed under U.S. Government agencies in your telephone directory or you
through SSA’s website at
.
may call Social Security at 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-827 (11-2012) ef (11-2012)
Page 2 of 2
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