Form SSA-3288 Consent for Release of Information

Social Security Administration

Consent for Release of Information
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). You may complete this form to release only the minor’s non-medical
records, if you are the natural or adoptive parent or legal guardian, acting on behalf of a minor child. We require proof of relationship, if
you are not the subject of the record. We may charge a fee for providing the information, if you are requesting the information for a
purpose unrelated to the administration of a program under the Social Security Act. If you are requesting information, such as a Social
Security Statement or benefit verification letter, you can also access this information by creating an account at
https://www.ssa.gov/myaccount/.
NOTE: Do NOT use this form to request:
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The release of a minor child’s medical records. Instead, visit your local Social Security office or call our toll-free
number, 1-800-772-1213 (TTY-1-800-325-0778), or
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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.
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Fill in the name, date of birth, and social security number of the subject of the record.
Fill in the name and address of the person or organization of where you want us to send the requested information.
Specify the reason you want us to release the information (e.g., litigation, investigation, determining eligibility for benefits). If
you are the natural or adoptive parent or legal guardian, acting on behalf of a minor child or legally incompetent adult, you
must state how the release of information is in the best interest of the minor child or legally incompetent adult.
Check the box next to the type(s) of information you want us to release including specific date ranges, where applicable.

NOTE: Unless otherwise specified, the consent form is valid for one-time use only. Also, it is valid for one year from the date of
signature, unless you are requesting medical records. A consent form that includes a request for medical records is valid for 90 days
from the date of signature.
Send or bring the completed form to the subject of the record’s local servicing office. To locate the appropriate servicing office, visit
https://secure.ssa.gov/ICON/main.jsp, and input the subject of the record’s zip code.

PRIVACY ACT STATEMENT
The Privacy Act (5 U.S.C. 552a) and Section 205(a) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from honoring the
request to release information or records about you. We will use the information you provide to respond to the request for Social
Security Administration (SSA) records. We may share the information for the following purposes, called routine uses:
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To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of its
programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized,
we may use and disclose this information in computer matching programs, in which our records are compared with other records to
establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these
programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled Claims Folders
System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0320, entitled Electronic Disability Claim File,
as published in the FR on December 22, 2003, at 68 FR 71210; and 60-0340, entitled FOIA and Privacy Act Record Request and
Appeal System, as published in the FR on July 13, 2016, at 81 FR 45352. Additional information, and a full listing of all our SORNs, is
available on our website at www.ssa.gov/privacy.

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. 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.

SSA-3288

Social Security Administration

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. **These are
not mandatory fields for the consent form to be acceptable. Please complete these fields in case we need to contact you about the consent form).

To: Social Security Administration
_________________________________

________________

_____________________________

* Full Name

* Date of Birth

* Full 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:
**PHONE NUMBER 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. If requesting medical records, do not check both boxes 7 and 8. We will not disclose records unless you include
specific date ranges where applicable.

1.
2.
3.
4.
5.
6.
7.
8.
9.

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Verification of Social Security Number
Current monthly Social Security benefit amount
Current monthly Supplemental Security Income payment amount
Social Security benefit amounts from date __________ to date__________
Supplemental Security Income payment amounts from date __________ to date__________
Medicare entitlement from date __________ to date__________
Medical records from date __________ to date __________
Complete medical records
Other Social Security record(s) (We will not honor a request for “any and all records” or “the entire file.” You must specify
which records you are seeking. For example, award/denial notices, benefit applications, appeals)

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

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 U.S.C. § 1746) 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 seeks or obtains access to records about another person under false pretenses is
punishable by a fine of up to $5,000.

*Signature: __________________________________________ *Date: _____________________
**Address: __________________________________________ **Daytime Phone: _________________
**Printed Name and Relationship: _______________________ **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

SSA-3288