Addendum to the Supporting Statement for SSA-3288
Privacy and Disclosure of Official Records and Information;
Availability of Information and Records to the Public;
20 CFR 401 and 402
OMB No. 0960-0566
Minor Revisions to the Collection Instrument
SSA is making the following revisions:
SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the first page of the form.
We are making minor revisions in the instructional text to improve clarity, grammar, and visual acuity. We are also adding the two required witness signature boxes erroneously omitted from earlier versions of the form.
Revision to the Collection Instrument Instructions (Page 1)
We list below the changes we are requesting to the SSA-3288 instructions page. Our grammatical changes in all instances are to transition from passive to active voice.
Change 1: Under the “Instructions for Using this Form,” we are modifying the paragraph and NOTE text.
Old Language:
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, you may complete this form to release only the minor's non-medical records. If you are requesting information for a purpose not directly related to the administration of any program under the Social Security Act, a fee may be charged.
NOTE: Do not use this form to:
Request us to release the medical records of a minor. Instead, contact your local office by calling 1-800-772-1213 (TTY-1-800-325-0778), or
Request information about your earnings or employment history. Instead, complete form SSA-7050-F4 at any Social Security office or online at www.ssa.gov/online/ssa-7050.pdf.
New Language:
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.
Justification 1: We are making changes to this text to improve clarity and grammar and to add a reminder about our fee charging policy for requesting information for non-program purposes.
Change 2: Under “How to Complete this Form,” we are modifying the text to improve clarity and grammar.
Old Language:
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 “all records” or the “entire file.” You must specify the information you are requesting and you must sign and date this form.
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 information applies.
Fill in the name and address of the individual (or organization) to whom you want us to release your information.
Indicate the reason you are requesting us to disclose the information.
Check the box(es) next to the type(s) of information you want us to release including the date ranges, if applicable.
You, the parent or legal guardian acting on behalf of a minor, or the legal guardian of a legally incompetent adult, must sign and date this form and provide a daytime phone number where you can be reached.
If you are not the person whose information is requested, state your relationship to that person. We may require proof of relationship.
New Language:
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.
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.
Justification 2: We are changing this text to improve clarity and grammar.
Change 3: Under the “PRIVACY ACT STATEMENT,” we are modifying the text.
Old Language:
Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. The information you provide will be used to respond to your request for SSA records information or process your request when we 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, in accordance with 5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the information provided 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. Information from these matching programs can be used to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and other Social Security programs are available from our Internet website at www.socialsecurity.gov or at your local Social Security office.
New Language:
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:
To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and or coverage;
To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level;
To comply with Federal laws requiring the disclosure of the information from our records; and,
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.
Justification 3: We are changing this text to improve clarity, grammar, and visual acuity.
Revision to the Collection Instrument Form (Page 2)
We are making the following changes to the face of form SSA-3288:
Change 4: Under “Consent for Release of Information,” we are modifying the instructional text.
Old Language:
SSA will not honor this form unless all required fields have been completed (*signifies required field).
New Language:
You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a required field).
Justification 4: We are making this change to improve clarity and grammar.
Change 5: Under “To: Social Security Administration,” we are renaming the three fill-in fields.
Old Language:
____________________________ _____________________ _______________________
*Name *Date of Birth *Social Security Number
New Language:
____________________________ ______________________ _________________________
*My Full Name *My Date of Birth *My Social Security Number
(MM/DD/YYYY)
Justification 5: We are making these changes to obtain the desired responses.
Change 6: Under “I authorize the Social Security Administration…,” we are renaming the two fill-in fields.
Old Language:
*Name *Organization
New Language:
*NAME OF PERSON OR ORGANIZATION *ADDRESS OF PERSON OR ORGANIZATION
Justification 6: Ware making these changes to obtain the desired responses.
Change 7: Under “I want this information released because:” we are modifying the instructional text.
Old Language:
There may be a charge for releasing information.
New Language:
We may charge a fee to release information for non-program purposes.
Justification 7: We are making this change to improve clarity and grammar.
Change 8: Under “Please release the following information…,” we are modifying the instructional text.
Old Language:
You must check at least one box. Also, SSA will not disclose records unless applicable date ranges are included.
New Language:
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.
Justification 8: We are making this change to improve clarity and to obtain the desired responses.
Change 9: We are numbering the check boxes and modifying instructional text.
Old Format:
Social Security Number
Current monthly Social Security benefit amount
Current monthly Supplemental Security Income payment amount
My benefit/payment amounts from _______________ to __________________
My Medicare entitlement from _______________ to __________________
Medical records from my claims folder(s) from _______________ to __________________
If you want SSA to release a minor's medical records, do not use this form but instead contact your local SSA office.
Complete medical records from my claims folder(s)
Other record(s) from my file (e.g. applications, questionnaires, consultative examination reports,
determinations, etc.) ___________________________________________________________________
____________________________________________________________________________________
New Format:
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__________
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)
8. Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application,
determination or questionnaire)
___________________________________________________________________________________
___________________________________________________________________________________
Justification 9: We are making this change to improve clarity, visual acuity, and to obtain the desired responses.
Change 10: We are modifying the attestation statement language.
Old Language:
I am the individual to whom the requested information/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 in accordance with 28 C.F.R. § 16.41(d)(2004) that I have examined all the information on this form, and on 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 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 any applicable fees must be paid by me.
New Language:
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.
Justification 10: We are making this change to improve clarity and grammar.
Change 11: Under the requester’s *Signature, we are adding a required field for the signee’s *Address.
Justification 11: We are adding an address field to support Operations’ policy of requiring requesters to send requests to the local servicing field office.
Change 12: Beside “Relationship,” we are modifying the parenthetical instructional text.
Old Language:
(if not the individual)
New Language:
(if not the subject of the record)
Justification 12: We are making this change to improve clarity.
Change 13: We are adding instructional text and two boxes for the signature and address of two witnesses.
New Language:
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 |
Address (Number and street, City, State, and Zip Code) |
Address (Number and street, City, State, and Zip Code |
Justification 13: We are adding this information because:
Our policy permits signatures by mark (X) (GN 03305.001B.3); and
We inadvertently omitted this required information from earlier versions of the form.
| File Type | application/msword |
| File Title | ADDENDUM TO SUPPORTING STATEMENT |
| Author | Naomi |
| Last Modified By | 889123 |
| File Modified | 2012-09-27 |
| File Created | 2012-09-27 |