SOP_NUMBER: 503.02-att-2 TITLE: Consent for Release of Information (SSA-3288 Form) REFERENCE_CODE: VK01-0002 DIVISION: Unknown TOPIC_AREA: 503.02 Policy-Reentry WORD_COUNT: 725 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/547593 URL: https://gps.press/sop-data/503.02-att-2/ SUMMARY: This is a Social Security Administration consent form used by GDC inmates to authorize the release of their Social Security records and information to designated recipients during reentry planning. The form allows inmates to specify what types of information (such as Social Security number, benefit amounts, Medicare coverage, or medical records) can be shared with parole boards, pre-release programs, work release programs, halfway houses, or schools. The completed form is placed in the inmate's institutional file and retained according to official DOC retention schedules. 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 ATTACHMENTS: 1. Certification of Prison Records URL: https://gps.press/sop-data/503.02-att-1/ 2. Consent for Release of Information (SSA-3288 Form) URL: https://gps.press/sop-data/503.02-att-2/ 3. TOPPSTEP Checklist URL: https://gps.press/sop-data/503.02-att-3/ 4. Authorization for Submission of Information to Obtain Georgia Driver's License or Identification Card URL: https://gps.press/sop-data/503.02-att-4/ 5. Reentry Checklist Narrative for State Prisons and Transitional Centers URL: https://gps.press/sop-data/503.02-att-5/ 6. Residence Verification Form: Georgia Department of Community Supervision, Department of Corrections, and/or Board of Pardons and Paroles URL: https://gps.press/sop-data/503.02-att-6/ 7. Problem Housing File Review URL: https://gps.press/sop-data/503.02-att-7/ ======================================================================== 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.