SOP 503.02-att-2: Consent for Release of Information (SSA-3288 Form)
Summary
Key Topics
- consent form
- Social Security Administration
- SSA-3288
- release of information
- reentry
- parole
- pre-release services
- work release
- halfway house
- benefit information
- medical records
- TOPPSTEP packet
Full Text
Page 1 of 2
Form Approved
OMB No. 0960-0566
Social Security Administration
# Consent for Release of Information
TO: Social Security Administration
Name________________________________ GDC:______________________________
Date of Birth_____________ Social Security Number____________________________
I authorize the Social Security Administration to release information or records about me to:
NAME ADDRESS
_____________________________ _______________________________________
_____________________________ _______________________________________
_____________________________ _______________________________________
I want this information released because:
PAROLE MONTH_________________MRD__________________HALF-WAY HOUSE TRANSFER
PARTICIPATING IN: PRE-RELEASE SOCIAL SERVICES PROGRAM; WORK RELEASE; SCHOOL (CIRCLE ONE
OR FILL IN THE BLANK PROVIDED) __
(There may be a charge for releasing information.)
Please release the following information:
X Social Security Number
Identifying information (includes date and place of birth, parents' names)
Monthly Social Security benefit amount
_ Monthly Supplemental Security Income payment amount
Information about benefits/payments I received from to ______
Information about my Medicare claim/coverage from to ______
(specify) _________________________________________________
Medical records
Record(s) from my file (specify) ______________________________
________________________________________________________
Other (specify) ____________________________________________
I am the individual to whom the information/record applies or that person's parent (if a minor) or legal guardian.
I know that if I make any representation which I know is false to obtain information from Social Security
records, I could be punished by a fine or imprisonment or both.
Signature: _________________________________________
(Show signatures, names, and addresses of two people if signed by mark.)
Date: Relationship: ____________________________
SSA-3288
Retention Schedule for DOC: Upon completion, this form shall be placed in the TOPPSTEP packet in the offender’s institutional file,
and the file shall be retained according to the official retention schedule for that file.
Page 2 of 2
Form Approved
OMB No. 0960-0566
Social Security Administration
# Consent for Release of Information
Please read these instructions carefully before completing this form.
When To Use Complete this form only if you want the Social Security Administration
This Form to give information or records about you to an individual or group (for example, a doctor,
or an insurance company).
Natural or adoptive parents or a legal guardian, acting on behalf of a minor, who want
us to release the minor's:
- nonmedical records, should use this form,
- medical records, should not use this form, but should contact us.
Note: Do not use this form to request information about your earnings or employment
history. To do this, complete Form SSA-7050-F3. You can get this form at any Social
Security office.
How To This consent form must be completed and signed only by:
Complete - the person to whom the information or record applies, or
This Form - the parent or legal guardian of a minor to whom the nonmedical
information applies, or
- the legal guardian of a legally incompetent adult to whom the
information applies.
To complete this form:
- Fill in 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 group to which we will
send the information.
- Fill in the reason you are requesting the information.
- Check the type(s) of information you want us to release.
- Sign and date the form. If you are not the person whose record we will
release, please state your relationship to that person.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the
Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB
control number.
TIME IT TAKES TO COMPLETE THIS FORM--We estimate that it will take you about 3 minutes to complete this form. This includes the time it will take to read
the instructions, gather the necessary facts and fill out the form. If you have comments or suggestions on this estimate, write to the Social Security Administration,
ATTN: Reports Clearance Officer, 1-A-21 Operations Bldg., Baltimore, MD 21235-0001. Send only comments relating to our "time it takes" estimate to the office
listed above. All requests for Social Security cards and other claims-related information should be sent to your local Social Security office, whose address is listed
under Social Security Administration in the U.S. Government section of your telephone directory.
SSA-3288
Retention Schedule for DOC: Upon completion, this form shall be placed in the TOPPSTEP packet in the offender’s institutional file,
and the file shall be retained according to the official retention schedule for that file.