Form Ssa 3288 PDF Details

The Social Security Administration (SSA) Form 3288, officially titled "Consent for Release of Information," serves a crucial function in facilitating the disclosure of personal, non-medical information to designated third parties, a decision not taken lightly by the SSA. Essential for those requiring the SSA to share information with individuals or entities such as doctors or insurance companies, this form carves out a process for consent that respects the privacy and autonomy of the individual it concerns, whether that be for themselves, a minor child, or a legally incompetent adult. With specific instructions that disallow the use of the form for requesting the release of a minor child's medical records or detailed earnings and employment history—which require alternative processes—the SSA-3288 form emphasizes specificity and informed consent. Completion requires the careful filling of all mandated fields, including personal identification details and the particular information to be released, alongside an explanation for the request. Furthermore, the form educates on the applicable charges for information provision, unless it pertains to the administration of a program under the Social Security Act. Through this instrument, the SSA not only upholds its statutory obligations under Section 205(a) of the Social Security Act but also aligns with broader principles of respect for individual rights, as articulated in the Privacy Act. Significantly, this form embodies a balance between facilitating necessary information exchange and safeguarding personal data privacy, an equilibrium critical in an age where information is both a powerful resource and a potential vulnerability.

QuestionAnswer
Form NameForm Ssa 3288
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesssa form 3288 printable, social security form 3288 printable, social security form ssa 3288, social security administration form 3288

Form Preview Example

Social Security Administration

Form Approved

 

Consent for Release of Information

OMB No. 0960-0566

 

 

Instructions for Using this Form

Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an individual or group (for example, a doctor or an insurance company). If you are the natural or adoptive parent or legal guardian, acting on behalf of a minor child, you may complete this form to release only the minor's non-medical records. We may charge a fee for providing information unrelated to the administration of a program under the Social Security Act.

NOTE: Do not use this form to:

Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our toll- free number, 1-800-772-1213 (TTY-1-800-325-0778), or

Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You can obtain form SSA-7050-F4 from your local Social Security office or online at www.ssa.gov/online/ssa-7050.pdf.

How to Complete this Form

We will not honor this form unless all required fields are completed. An asterisk (*) indicates a required field. Also, we will not honor blanket requests for "any and all records" or the "entire file." You must specify the information you are requesting and you must sign and date this form. We may charge a fee to release information for non-program purposes.

Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person to whom the requested information pertains.

Fill in the name and address of the person or organization where you want us to send the requested information.

Specify the reason you want us to release the information.

Check the box next to the type(s) of information you want us to release including the date ranges, where applicable.

For non-medical information, you, the parent or the legal guardian acting on behalf of a minor child or legally incompetent adult, must sign and date this form and provide a daytime phone number.

If you are not the individual to whom the requested information pertains, state your relationship to that person. We may require proof of relationship.

PRIVACY ACT STATEMENT

Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. We will use the information you provide to respond to your request for access to the records we maintain about you or to process your request to release your records to a third party. You do not have to provide the requested information. Your response is voluntary; however, we cannot honor your request to release information or records about you to another person or organization without your consent. We rarely use the information provided on this form for any purpose other than to respond to requests for SSA records information. However, the Privacy Act (5 U.S.C. § 552a(b)) permits us to disclose the information you provide on this form in accordance with approved routine uses, which include but are not limited to the following:

1.To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and or coverage; 2.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; 3.To comply with Federal laws requiring the disclosure of the information from our records; and,

4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of SSA programs.

We may also use the information you provide when we match records by computer. Computer matching programs compare our records with those of other Federal, State, or local government agencies. We use information from these matching programs to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of incorrect payments or overpayments under these programs. Additional information regarding this form, routine uses of information, and other Social Security programs is available on our Internet website, www.socialsecurity.gov, or at your local 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 3 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 through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S. Government agencies in your telephone directory or you may call 1-800-772-1213 (TYY 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-3288 (11-2016) uf

Destroy Prior Editions

Social Security Administration

Form Approved

 

Consent for Release of Information

OMB No. 0960-0566

You must complete all required fields. We will not honor your request unless all required fields are completed. (*Signifies a required field. **Please complete these fields in case we need to contact you about the consent form).

TO: Social Security Administration

 

*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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*I want this information released because:

We may charge a fee to release information for non-program purposes.

*Please release the following information selected from the list below:

Check at least one box. We will not disclose records unless you include date ranges where applicable.

1.

2.

3.

4.

5.

6.

Verification of Social Security Number

Current monthly Social Security benefit amount

Current monthly Supplemental Security Income payment amount

My benefit or payment amounts from date

 

 

to date

 

 

My Medicare entitlement from date

 

 

to date

 

 

 

Medical records from my claims folder(s) from date

 

 

 

to date

 

 

7.

8.

If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office.

Complete medical records from my claims folder(s)

Other record(s) from my file (We will not honor a request for "any and all records" or "the entire file." You must specify other records; e.g., consultative exams, award/denial notices, benefit applications, appeals, questionnaires,

doctor reports, determinations.)

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 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 I must pay all applicable fees for requesting information for a non-program-related purpose.

*Signature:

*Date:

 

 

 

 

 

 

 

**Address:

**Daytime Phone:

 

 

 

 

 

 

 

 

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.

1.Signature of witness

2.Signature of witness

Address(Number and street,City,State, and Zip Code)

Address(Number and street,City,State, and Zip Code)

Form SSA-3288 (11-2016) uf

How to Edit Form Ssa 3288 Online for Free

You can complete social security form ssa 3288 easily in our PDFinity® PDF editor. The tool is continually updated by us, acquiring awesome features and turning out to be better. Should you be looking to get going, here's what it will take:

Step 1: First, access the pdf tool by clicking the "Get Form Button" above on this webpage.

Step 2: Once you access the online editor, there'll be the form made ready to be filled in. In addition to filling in various blanks, you may also perform several other actions with the file, including adding your own textual content, modifying the original textual content, inserting images, signing the document, and more.

Completing this form usually requires attention to detail. Make certain all mandatory areas are completed correctly.

1. Start filling out the social security form ssa 3288 with a number of necessary blank fields. Get all of the required information and be sure absolutely nothing is left out!

A way to fill in release information part 1

2. The subsequent step is usually to fill in these particular fields: My benefit or payment amounts from, My Medicare entitlement from date, If you want us to release a minor, Complete medical records from my, Other records from my file We will, I am the individual to whom the, Signature, Address, Relationship if not the subject of, Date, Daytime Phone, and Daytime Phone.

If you want us to release a minor, My benefit or payment amounts from, and Address inside release information

Always be extremely mindful while filling out If you want us to release a minor and My benefit or payment amounts from, since this is the part in which many people make some mistakes.

3. Your next stage will be simple - fill in all the fields in Signature of witness, Signature of witness, AddressNumber and streetCityState, AddressNumber and streetCityState, and Form SSA uf to conclude the current step.

Step # 3 for filling in release information

Step 3: After looking through your form fields, press "Done" and you're good to go! Try a free trial plan with us and obtain direct access to social security form ssa 3288 - with all transformations saved and accessible inside your FormsPal account page. When using FormsPal, you can certainly complete documents without worrying about database incidents or entries getting distributed. Our protected system makes sure that your private details are maintained safely.